Provider Demographics
NPI:1104378702
Name:FAIN, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FAIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E SHOW LOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7831
Mailing Address - Country:US
Mailing Address - Phone:928-537-6371
Mailing Address - Fax:
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7831
Practice Address - Country:US
Practice Address - Phone:928-537-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-29
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant