Provider Demographics
NPI:1811231194
Name:JETER, JOSHUA K (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:K
Last Name:JETER
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 1:2122 E HIGHLAND AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4744
Mailing Address - Country:US
Mailing Address - Phone:602-553-3113
Mailing Address - Fax:602-667-7991
Practice Address - Street 1:2122 E HIGHLAND AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4744
Practice Address - Country:US
Practice Address - Phone:602-553-3113
Practice Address - Fax:602-667-7991
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003655363A00000X
AZ6172363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant