Provider Demographics
NPI:1235289240
Name:JAMES, KERRY JOE (SA-C)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:JOE
Last Name:JAMES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1398 PARKVIEW ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4643
Mailing Address - Country:US
Mailing Address - Phone:314-392-3998
Mailing Address - Fax:618-883-2849
Practice Address - Street 1:1398 PARKVIEW ESTATES DR
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63021-4643
Practice Address - Country:US
Practice Address - Phone:314-392-3998
Practice Address - Fax:618-883-2849
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO06-179363AS0400X
IL238000599246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant