Provider Demographics
NPI:1689612012
Name:PRIMEAU, JESSE R (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:PRIMEAU
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 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1777
Mailing Address - Fax:
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1486-23363A00000X
MI5601003683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41960500Medicaid
WI41960500Medicaid