Provider Demographics
NPI:1821749383
Name:ILLICH, JESSE (PAS1)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ILLICH
Suffix:
Gender:M
Credentials:PAS1
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 1490
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-1490
Mailing Address - Country:US
Mailing Address - Phone:828-262-3886
Mailing Address - Fax:828-265-4816
Practice Address - Street 1:240 HIGHWAY 105 EXT STE 100
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4291
Practice Address - Country:US
Practice Address - Phone:828-264-7311
Practice Address - Fax:828-264-7907
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-13685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program