Provider Demographics
NPI:1700308871
Name:FERTIG, JESSICA ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:FERTIG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELLEN
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2019 GALISTEO ST STE N9B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2111
Mailing Address - Country:US
Mailing Address - Phone:505-986-9688
Mailing Address - Fax:505-986-9090
Practice Address - Street 1:2019 GALISTEO ST STE N9B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2111
Practice Address - Country:US
Practice Address - Phone:505-986-9688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant