Provider Demographics
NPI:1407194954
Name:WARD, JIMMIE S SR (PA-C)
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:S
Last Name:WARD
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:125 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:MI
Practice Address - Zip Code:48756-5117
Practice Address - Country:US
Practice Address - Phone:989-873-3352
Practice Address - Fax:989-873-3949
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006560363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407194954Medicaid
MIMI1172006Medicare UPIN