1194713701 NPI number — JEFFERY JUSTIN KERN PA-C

Table of content: JEFFERY JUSTIN KERN PA-C (NPI 1194713701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194713701 NPI number — JEFFERY JUSTIN KERN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KERN
Provider First Name:
JEFFERY
Provider Middle Name:
JUSTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194713701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843013
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-3013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-895-1989
Provider Business Mailing Address Fax Number:
910-895-9666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 PHYSICIANS PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKINGHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28379-5204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-895-1989
Provider Business Practice Location Address Fax Number:
910-895-9666
Provider Enumeration Date:
10/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  103521 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103521 . This is a "STATE LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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