Provider Demographics
NPI:1184027732
Name:JEZ, ANDREA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JEZ
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 1:500 LINCOLN PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6410
Mailing Address - Country:US
Mailing Address - Phone:937-531-5020
Mailing Address - Fax:
Practice Address - Street 1:500 LINCOLN PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6410
Practice Address - Country:US
Practice Address - Phone:937-531-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001006685363A00000X
OH50.004123RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant