Provider Demographics
NPI:1114988292
Name:JETHRO, VIRGINIA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:A
Last Name:JETHRO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:A
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1110 SE CARY PKWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7420
Mailing Address - Country:US
Mailing Address - Phone:919-463-1101
Mailing Address - Fax:919-463-1110
Practice Address - Street 1:1110 SE CARY PKWY
Practice Address - Street 2:SUITE 206
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7420
Practice Address - Country:US
Practice Address - Phone:919-463-1101
Practice Address - Fax:919-463-1110
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103811363AM0700X
PAMA-052635363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical