Provider Demographics
NPI:1295817237
Name:MYERS, JACK EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:MYERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 OAK ST
Mailing Address - Street 2:P.O. BOX 10
Mailing Address - City:SHELDON
Mailing Address - State:IA
Mailing Address - Zip Code:51201-1242
Mailing Address - Country:US
Mailing Address - Phone:712-324-5356
Mailing Address - Fax:712-324-6515
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1242
Practice Address - Country:US
Practice Address - Phone:712-324-5356
Practice Address - Fax:712-324-6515
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0254656Medicaid
IA0638593Medicaid
IA168506Medicare ID - Type UnspecifiedRHC # SHELDON
IA0254656Medicaid
IA163875AMedicare ID - Type UnspecifiedRHC # SANBORN
IA42047Medicare ID - Type UnspecifiedPART B GROUP #