Provider Demographics
NPI:1689267890
Name:ANDERSON, JARED ROSS (PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:ROSS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10561 JEFFREYS ST STE 230
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4268
Mailing Address - Country:US
Mailing Address - Phone:702-819-8536
Mailing Address - Fax:702-948-1088
Practice Address - Street 1:10561 JEFFREYS ST STE 230
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4268
Practice Address - Country:US
Practice Address - Phone:702-819-8536
Practice Address - Fax:702-948-1088
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVPA2709363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program