Provider Demographics
NPI:1689941346
Name:SPERRY, SAMUEL JARED (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JARED
Last Name:SPERRY
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 1:401 E HIGHLAND AVE STE 351
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3830
Mailing Address - Country:US
Mailing Address - Phone:909-475-8611
Mailing Address - Fax:909-475-2566
Practice Address - Street 1:401 E HIGHLAND AVE STE 351
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3830
Practice Address - Country:US
Practice Address - Phone:909-475-8611
Practice Address - Fax:909-475-2566
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22002363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical