Basic Information
| Provider Information | |||||||||
| NPI: | 1316373343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALVARESE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CALVARESE | ||||||||
| OtherFirstName: | JONATHAN | ||||||||
| OtherMiddleName: | P | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 W FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | LUCEDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394525836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 W FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | LUCEDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394525836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330123 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.