Provider Demographics
NPI:1700214673
Name:PAULLUS, JEFFREY (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:PAULLUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 E GREENLEE AVE
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-7238
Mailing Address - Country:US
Mailing Address - Phone:909-435-6531
Mailing Address - Fax:
Practice Address - Street 1:1016 E GREENLEE AVE
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-7238
Practice Address - Country:US
Practice Address - Phone:909-435-6531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant