Provider Demographics
NPI:1750363859
Name:JEWELL, TAMMY R (PA)
Entity type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:R
Last Name:JEWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 932163
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0001
Mailing Address - Country:US
Mailing Address - Phone:586-412-4000
Mailing Address - Fax:586-412-4100
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2160
Practice Address - Fax:859-301-3932
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500416400Medicaid
P00227500OtherRRMC
P00227500OtherRRMC
P74320Medicare UPIN