Provider Demographics
NPI:1851279962
Name:PROTHERO, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:PROTHERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 FROMAN DR
Mailing Address - Street 2:
Mailing Address - City:BADEN
Mailing Address - State:PA
Mailing Address - Zip Code:15005-2718
Mailing Address - Country:US
Mailing Address - Phone:724-841-1255
Mailing Address - Fax:
Practice Address - Street 1:2570 HAYMAKER RD
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3513
Practice Address - Country:US
Practice Address - Phone:412-858-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty