Healthcare Provider Details

I. General information

NPI: 1154598647
Provider Name (Legal Business Name): MR. JEFFREY SUMNER MCCOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 TOMALES RD
PETALUMA CA
94952-5002
US

IV. Provider business mailing address

2810 S OAK ST
PORT ANGELES WA
98362-6921
US

V. Phone/Fax

Practice location:
  • Phone: 360-477-8679
  • Fax:
Mailing address:
  • Phone: 360-477-8679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: