Provider Demographics
NPI:1295761369
Name:HALL, JERRY (PA-C)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:HALL
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 1:168 N CASEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PIGEON
Mailing Address - State:MI
Mailing Address - Zip Code:48755-9704
Mailing Address - Country:US
Mailing Address - Phone:989-453-5210
Mailing Address - Fax:
Practice Address - Street 1:168 N CASEVILLE RD
Practice Address - Street 2:
Practice Address - City:PIGEON
Practice Address - State:MI
Practice Address - Zip Code:48755-9704
Practice Address - Country:US
Practice Address - Phone:989-453-2141
Practice Address - Fax:989-453-4550
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR66532Medicare UPIN
MI233977Medicare Oscar/Certification
MI0P09650003Medicare PIN