Provider Demographics
NPI:1003351115
Name:PRIDDY, JERRY (PA-C)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:PRIDDY
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:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:619 E MASON ST STE 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1080
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-2552
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006117363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical