Provider Demographics
NPI:1740376102
Name:PERRY, JON E (PA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:PERRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 GARDEN PL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-7767
Mailing Address - Country:US
Mailing Address - Phone:575-489-4750
Mailing Address - Fax:575-586-4414
Practice Address - Street 1:1700 N UNION AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3267
Practice Address - Country:US
Practice Address - Phone:575-489-4750
Practice Address - Fax:575-586-4414
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22153363A00000X
IL085-002088363A00000X
IDPA-848363AM0700X
NMPA2011-0062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ04423Medicare UPIN