Basic Information
| Provider Information | |||||||||
| NPI: | 1548542178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOCK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 572 BEACON LAKE DR | ||||||||
| Address2: | APT 7 | ||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488541972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867471853 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488541387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172440120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2011 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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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 | 5601006165 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.