Jack W Romano, PA
Individual provider Active NPI Surgical Physician Assistant · Kimberly, WI
NPI 1114059987 · NPPES record last updated May 1, 2026
Key facts
- NPI
- 1114059987
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Surgical Physician Assistant 363AS0400X
- License
- PA10002119 (WA)
- Practice address
- 300 W Papermill Run Unit 311
Kimberly, WI 54136-5507 - Phone
- (206) 940-0962
- NPI assigned
- Mar 9, 2007
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA10002119 | WA | MD | Surgical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Eastside Fusion, LLC. | Surgical | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgical Physician Assistant | 363AS0400X | PA10002119 | WA | Yes |
Addresses
Primary practice location
300 W Papermill Run Unit 311
Kimberly, WI 54136-5507
Mailing address
300 W Papermill Run Unit 311
Kimberly, WI 54136-5507
Phone (206) 940-0962
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| G8864515 | Other | WA | MEDICARE PTAN |
Other providers in Kimberly, WI
- Savanah Sara Ovans
- Zachary Patrick Papendieck
- Leah R Peterson
- Kay Pullen
- Renard Foot and Ankle LLC
- Callie Irene Romenesko
- Glen E Rooyakkers
- Wanda J Rooyakkers
- Sarah Marie Schultz
- Kyle S Schumacher
All providers in Kimberly, WI · Surgical Physician Assistant in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 1, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.