Healthcare Provider Details

I. General information

NPI: 1497513329
Provider Name (Legal Business Name): JAYDEN CHARLES BITTORF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/20/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D. L. INGRAM AVE, BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

1900 ENLOE DR
CLOVIS NM
88101-8686
US

V. Phone/Fax

Practice location:
  • Phone: 757-904-3896
  • Fax:
Mailing address:
  • Phone:
  • 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: