MEDICARE: MR. KERRY L MAYHEW PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA10001928	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	127522	OTHER	WA	L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235244096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KERRY L MAYHEW PA-C

Provider Business Mailing Address
First Line	:	25 HAUSSLER RD
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9591
Country	:	US
Telephone Number	:	509-826-6832
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 KOALA AVE
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9247
Country	:	US
Telephone Number	:	509-826-8443
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	12/11/2007

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