Basic Information
| Provider Information | |||||||||
| NPI: | 1063452266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEISER | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4030 SMITH RD | ||||||||
| Address2: | 300 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452091957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134219434 | ||||||||
| FaxNumber: | 5133452606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 S MAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372087240 | ||||||||
| FaxNumber: | 9372087242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA13591 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.000812 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0132950 | 05 | ND | MEDICAID |