Provider Demographics
NPI:1790080182
Name:AVERY, JAMES LESTER (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LESTER
Last Name:AVERY
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:PO BOX 1364
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-1146
Mailing Address - Country:US
Mailing Address - Phone:209-262-8386
Mailing Address - Fax:
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:D-460
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-472-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-17
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20641363L00000X
CAPA20054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner