Provider Demographics
NPI:1467479550
Name:STORK, JERRY LEE (PA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:STORK
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 1:3688 VETERANS MEMORIAL DR
Mailing Address - Street 2:200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7402
Mailing Address - Fax:601-554-7488
Practice Address - Street 1:3688 VETERANS MEMORIAL DR
Practice Address - Street 2:200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8246
Practice Address - Country:US
Practice Address - Phone:601-554-7402
Practice Address - Fax:601-554-7488
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103513363AM0700X
MSPA00079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6928ZMedicare ID - Type Unspecified
FLQ63500Medicare UPIN