Healthcare Provider Details

I. General information

NPI: 1235289240
Provider Name (Legal Business Name): KERRY JOE JAMES SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 PARKVIEW ESTATES DR
ELLISVILLE MO
63021-4643
US

IV. Provider business mailing address

1398 PARKVIEW ESTATES DR
ELLISVILLE MO
63021-4643
US

V. Phone/Fax

Practice location:
  • Phone: 314-392-3998
  • Fax: 618-883-2849
Mailing address:
  • Phone: 314-392-3998
  • Fax: 618-883-2849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number06-179
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000599
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: