Provider Demographics
NPI:1790319028
Name:MCCOMIS, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MCCOMIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4853
Mailing Address - Country:US
Mailing Address - Phone:681-888-3117
Mailing Address - Fax:
Practice Address - Street 1:106 SHOPPERS WAY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-0530
Practice Address - Country:US
Practice Address - Phone:912-275-8028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN289175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily