Provider Demographics
NPI:1225072614
Name:ULMER, JEFFERY LANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:LANE
Last Name:ULMER
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 1:1102 CRESTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-5513
Mailing Address - Country:US
Mailing Address - Phone:479-394-7301
Mailing Address - Fax:479-394-7160
Practice Address - Street 1:1102 CRESTWOOD CIR
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5513
Practice Address - Country:US
Practice Address - Phone:479-394-7301
Practice Address - Fax:479-394-7160
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-116363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR53482P033Medicare ID - Type UnspecifiedAR MEDICARE PROVIDER #