Provider Demographics
NPI:1295351138
Name:DEATON, JIMMY (PA-C)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:DEATON
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 1:1234 E PITTSBURG CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-9046
Mailing Address - Country:US
Mailing Address - Phone:606-813-5556
Mailing Address - Fax:
Practice Address - Street 1:181 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MI
Practice Address - Zip Code:49082-1165
Practice Address - Country:US
Practice Address - Phone:517-639-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant