Provider Demographics
NPI:1497977235
Name:HUMPHREY, JAY RALEIGH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:RALEIGH
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:226 MILL HILL AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2826
Mailing Address - Country:US
Mailing Address - Phone:203-453-0677
Mailing Address - Fax:203-458-7015
Practice Address - Street 1:652 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2719
Practice Address - Country:US
Practice Address - Phone:203-453-0677
Practice Address - Fax:203-458-7015
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT002111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant