Provider Demographics
NPI:1245746114
Name:DAW, GERERON JERALD (MT)
Entity Type:Individual
Prefix:
First Name:GERERON
Middle Name:JERALD
Last Name:DAW
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0368
Mailing Address - Country:US
Mailing Address - Phone:928-697-4140
Mailing Address - Fax:
Practice Address - Street 1:394.3 HIGHWAY 160
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4140
Practice Address - Fax:928-697-4142
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213216246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist