Provider Demographics
NPI:1003845280
Name:VITAMVAS, JEREMY A (PA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:VITAMVAS
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 1:5885 SUNNYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4203
Mailing Address - Country:US
Mailing Address - Phone:712-266-2760
Mailing Address - Fax:712-266-2719
Practice Address - Street 1:5885 SUNNYBROOK DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4203
Practice Address - Country:US
Practice Address - Phone:712-266-2760
Practice Address - Fax:712-266-2719
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA911858433Medicaid
NEP89260Medicare UPIN