Provider Demographics
NPI:1437150380
Name:JAQUITH, PHIL D (PA)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:D
Last Name:JAQUITH
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 1:1104 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3306
Mailing Address - Country:US
Mailing Address - Phone:605-665-7841
Mailing Address - Fax:605-665-0546
Practice Address - Street 1:101 S PLUM ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3306
Practice Address - Country:US
Practice Address - Phone:605-624-8643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0462363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6822814Medicaid
SD6822814Medicaid
SDP24800Medicare UPIN