Provider Demographics
NPI:1336347087
Name:HOULE, JEROME L IV (PA-C)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:HOULE
Suffix:IV
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR STREET
Mailing Address - Street 2:SUITE 700
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-3765
Mailing Address - Country:US
Mailing Address - Phone:860-696-2040
Mailing Address - Fax:860-696-2050
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 815
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-696-2060
Practice Address - Fax:860-696-2065
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001914363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004026712Medicaid
1336347087OtherNPI
CTD40001756 - C00814Medicare PIN