Provider Demographics
NPI:1952942195
Name:CRUZ, JESSICA ALEXANDRA (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALEXANDRA
Last Name:CRUZ
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:ZEHRUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1030 LEEPIKE CT
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6008
Mailing Address - Country:US
Mailing Address - Phone:208-669-2777
Mailing Address - Fax:
Practice Address - Street 1:213 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2700
Practice Address - Country:US
Practice Address - Phone:208-882-7565
Practice Address - Fax:208-882-7567
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant