Provider Demographics
NPI:1851339436
Name:BELVILLE, JESSE (PA)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:BELVILLE
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 1:333 N. 14TH
Mailing Address - Street 2:
Mailing Address - City:WAKEENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67672
Mailing Address - Country:US
Mailing Address - Phone:954-693-0000
Mailing Address - Fax:954-693-0005
Practice Address - Street 1:333 N. 14TH
Practice Address - Street 2:
Practice Address - City:WAKEENEY
Practice Address - State:KS
Practice Address - Zip Code:67672
Practice Address - Country:US
Practice Address - Phone:785-743-2124
Practice Address - Fax:785-743-2265
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01357363A00000X
TXPA02964207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S59748Medicare UPIN