Provider Demographics
NPI:1114360815
Name:PATRICK, JEREMY WALKER (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:WALKER
Last Name:PATRICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVIANO MDG
Mailing Address - Street 2:UNIT 6180
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DOD USAF NATO BASE
Practice Address - Street 2:
Practice Address - City:AVIANO
Practice Address - State:PN
Practice Address - Zip Code:09603
Practice Address - Country:IT
Practice Address - Phone:632-632-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1762363A00000X
WAPA60567501363AS0400X
GA9709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8941152Medicare PIN