Provider Demographics
NPI:1184686834
Name:WELSH, JEREMY M (RPA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:WELSH
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W. TAFT RD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-4868
Mailing Address - Country:US
Mailing Address - Phone:315-452-2333
Mailing Address - Fax:315-452-2336
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2333
Practice Address - Fax:315-452-2336
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009596207P00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02565557Medicaid
NY02565557Medicaid
NYJ400050832Medicare PIN
NYJ400012272Medicare PIN
NYPA0107Medicare ID - Type Unspecified