Provider Demographics
NPI:1164404794
Name:CHESLEY, JERRY W (PA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:CHESLEY
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 1:172 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-2510
Mailing Address - Country:US
Mailing Address - Phone:605-353-6200
Mailing Address - Fax:605-353-6593
Practice Address - Street 1:172 4TH ST SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2510
Practice Address - Country:US
Practice Address - Phone:605-353-6200
Practice Address - Fax:605-353-6593
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6826000Medicaid
5478Medicare ID - Type Unspecified