Provider Demographics
NPI:1346399185
Name:JENKINS, DAVID L (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:JENKINS
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 1:1211 S DOUGLAS HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4982
Mailing Address - Country:US
Mailing Address - Phone:307-685-3375
Mailing Address - Fax:
Practice Address - Street 1:1211 S DOUGLAS HWY STE 100
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4982
Practice Address - Country:US
Practice Address - Phone:307-685-3375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4303780Medicaid
MTQ16899Medicare UPIN