Individual
JACK PROTHERO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2566 HAYMAKER RD STE 304, MONROEVILLE, PA 15146-3555
(412) 858-3070
Mailing address
2566 HAYMAKER RD STE 304, MONROEVILLE, PA 15146-3555
(412) 858-3070
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
MA067306
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
16688712
CAQH
—
Enumeration date
08/26/2025
Last updated
12/16/2025
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