Provider Demographics
NPI:1720155914
Name:BAILES, JEFFERY MARTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:MARTIN
Last Name:BAILES
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 1:703 HARPOLD AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1339
Mailing Address - Country:US
Mailing Address - Phone:304-440-4344
Mailing Address - Fax:
Practice Address - Street 1:215 5TH ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-4033
Practice Address - Country:US
Practice Address - Phone:740-376-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant