Provider Demographics
NPI:1932294550
Name:BERTHOT, JEFFREY SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:BERTHOT
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 1:4800 NE STALLINGS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1249
Mailing Address - Country:US
Mailing Address - Phone:936-569-9443
Mailing Address - Fax:
Practice Address - Street 1:4800 NE STALLINGS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1249
Practice Address - Country:US
Practice Address - Phone:936-569-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K9359Medicare PIN
TX8D1714Medicare ID - Type Unspecified
TXQ35657Medicare UPIN