Provider Demographics
NPI:1841213212
Name:KUTSCHERA, JEROME DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:DAVID
Last Name:KUTSCHERA
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:P.O. BOX 61
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:VA
Mailing Address - Zip Code:24465
Mailing Address - Country:US
Mailing Address - Phone:540-383-4031
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIRCLE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-5129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ42977Medicare UPIN