Healthcare Provider Details

I. General information

NPI: 1770689150
Provider Name (Legal Business Name): JEREMY BICKETT P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W RAHN RD
DAYTON OH
45429-2219
US

IV. Provider business mailing address

33 W RAHN RD
DAYTON OH
45429-2219
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-8990
  • Fax: 937-433-8691
Mailing address:
  • Phone: 937-433-8990
  • Fax: 937-433-8691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50002487
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50-002487
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: