Provider Demographics
NPI:1811957871
Name:SECREST, JON ANDREW (PA)
Entity type:Individual
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First Name:JON
Middle Name:ANDREW
Last Name:SECREST
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Gender:M
Credentials:PA
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Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 200
Mailing Address - Street 2:(ATTN) FORSYTH MEDICAL GROUP
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-277-2435
Mailing Address - Fax:336-277-9275
Practice Address - Street 1:291 BROAD ST
Practice Address - Street 2:DBA KERNERSVILLE FAMILY PRACTICE
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2932
Practice Address - Country:US
Practice Address - Phone:336-993-8181
Practice Address - Fax:336-996-9538
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-10-25
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Provider Licenses
StateLicense IDTaxonomies
NC67247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS68043Medicare UPIN
NY2748304Medicare ID - Type Unspecified