Provider Demographics
NPI:1932725678
Name:SIEGFRIED, JAMIE M
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:M
Last Name:SIEGFRIED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:M
Other - Last Name:HOUSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:360 RICHARD HARRISON WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-1119
Mailing Address - Country:US
Mailing Address - Phone:814-661-5764
Mailing Address - Fax:
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-728-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1173754Medicaid