Provider Demographics
NPI:1134102635
Name:FIELDER, JEANNE LOUISE (PA C)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:LOUISE
Last Name:FIELDER
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:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0178
Mailing Address - Country:US
Mailing Address - Phone:269-657-2550
Mailing Address - Fax:269-657-2285
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-0178
Practice Address - Country:US
Practice Address - Phone:269-657-2550
Practice Address - Fax:269-657-2285
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MF0846949OtherDEA
MIR65885Medicare UPIN