=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770689150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY BICKETT P.A.-C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 07/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 W RAHN RD
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45429-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-433-8990
-----------------------------------------------------
Fax | 937-433-8691
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 W RAHN RD
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45429-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-433-8990
-----------------------------------------------------
Fax | 937-433-8691
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 50-002487
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 50002487
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------