Provider Demographics
NPI:1811915689
Name:FOX, JEFFREY J (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:FOX
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 1:1250 E MICHIGAN AVE
Mailing Address - Street 2:C/O PAYER ENROLLMENT
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-7074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-7074
Practice Address - Country:US
Practice Address - Phone:989-348-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F96001OtherBLUE SHIELD
S59064Medicare UPIN
MI700F96001OtherBLUE SHIELD