Provider Demographics
NPI:1619283066
Name:HERZIG, JAMIE E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:E
Last Name:HERZIG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:WILLOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 DAVIS GROVE CIR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-2580
Mailing Address - Country:US
Mailing Address - Phone:919-436-3777
Mailing Address - Fax:
Practice Address - Street 1:204 DAVIS GROVE CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-2580
Practice Address - Country:US
Practice Address - Phone:919-436-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054475363A00000X
VA0110004031363A00000X
NC0010-05088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAWI191136Medicare PIN