Healthcare Provider Details

I. General information

NPI: 1255416384
Provider Name (Legal Business Name): JERRY WAYNE IERY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 DEPOT DR
SOUTH SHORE KY
41175
US

IV. Provider business mailing address

PO BOX 550
VANCEBURG KY
41179
US

V. Phone/Fax

Practice location:
  • Phone: 606-932-2271
  • Fax: 606-932-2273
Mailing address:
  • Phone: 606-796-3029
  • Fax: 606-796-6221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA983
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1074488
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA983
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: