Provider Demographics
NPI:1356711535
Name:SHIFFLETT, JEREMY (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:SHIFFLETT
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 1:542 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-3600
Mailing Address - Country:US
Mailing Address - Phone:570-360-7259
Mailing Address - Fax:
Practice Address - Street 1:133 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-4071
Practice Address - Country:US
Practice Address - Phone:434-792-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant