Basic Information
| Provider Information | |||||||||
| NPI: | 1902208309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SILLAMAN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1380 E STROOP RD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454294926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372933486 | ||||||||
| FaxNumber: | 9372933605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 E STROOP RD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454294926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372944356 | ||||||||
| FaxNumber: | 9372972381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50004125 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0110639 | 05 | OH | MEDICAID |