Provider Demographics
NPI:1760408405
Name:BOYETT, JEFFREY S (PA - C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:BOYETT
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 1:3931 STOCKTON HILL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2426
Mailing Address - Country:US
Mailing Address - Phone:928-681-6100
Mailing Address - Fax:928-681-6103
Practice Address - Street 1:3931 STOCKTON HILL RD
Practice Address - Street 2:SUITE C
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2426
Practice Address - Country:US
Practice Address - Phone:928-681-6100
Practice Address - Fax:928-681-6103
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2139363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ568545Medicaid
AZ65361Medicare ID - Type Unspecified
AZ568545Medicaid