Provider Demographics
NPI:1720028095
Name:PLATT, JEREMY D (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:PLATT
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:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:1001 WILLOW CREEK RD STE 3100
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1614
Practice Address - Country:US
Practice Address - Phone:928-445-4818
Practice Address - Fax:928-445-4837
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3348363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ629253Medicaid