Provider Demographics
NPI:1548203003
Name:PERRY, JAMES (PAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:PERRY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-458-3830
Mailing Address - Fax:260-458-3831
Practice Address - Street 1:7333 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6280
Practice Address - Country:US
Practice Address - Phone:260-458-3830
Practice Address - Fax:260-458-3831
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000431A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ50010Medicare UPIN
IN090430WWWWMedicare ID - Type Unspecified