Provider Demographics
NPI:1508835992
Name:AVERY, JEFFREY LOUIS (PAC, MPAS)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LOUIS
Last Name:AVERY
Suffix:
Gender:M
Credentials:PAC, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1040
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:4433 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-771-2220
Practice Address - Fax:607-251-2635
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003068L363A00000X
NY007379-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P07822Medicare UPIN
PA043363N83Medicare ID - Type Unspecified