Provider Demographics
NPI:1164456281
Name:FINE, JEFFREY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:FINE
Suffix:
Gender:M
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 1:79 WEST ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-2426
Mailing Address - Country:US
Mailing Address - Phone:410-268-3627
Mailing Address - Fax:410-267-6372
Practice Address - Street 1:79 WEST ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-2426
Practice Address - Country:US
Practice Address - Phone:410-268-3627
Practice Address - Fax:410-267-6372
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001411363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD068NN101Medicare ID - Type Unspecified