Healthcare Provider Details

I. General information

NPI: 1083761985
Provider Name (Legal Business Name): JAY MITCHELL HARDY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 414 BOX 1393
APO AE
09173
DE

IV. Provider business mailing address

CMR 414 BOX 1393
APO AE
09173
DE

V. Phone/Fax

Practice location:
  • Phone: 011499498905863
  • Fax:
Mailing address:
  • Phone: 011499498905863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: