Provider Demographics
NPI:1114152758
Name:ELLIOTT, JERRY G (NP-C)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:G
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-946-9611
Practice Address - Fax:509-942-2185
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-35393363L00000X
IDNP-917A363L00000X
WAAP60240764363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002803300Medicaid