Provider Demographics
NPI:1861457525
Name:EVERSON, JEFFREY J (PAC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:EVERSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 26TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2203
Mailing Address - Country:US
Mailing Address - Phone:608-643-2471
Mailing Address - Fax:608-643-4788
Practice Address - Street 1:260 26TH ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2203
Practice Address - Country:US
Practice Address - Phone:608-643-2471
Practice Address - Fax:608-643-4788
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1048363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42977700Medicaid
S77790Medicare UPIN
WI42977700Medicaid