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NPI Code Detail

MEDICARE: JON ANDREW SECREST PA

MEDICARE: JON ANDREW SECREST PA
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
1363A00000XPhysician Assistant67247NC

General Provider Information

NPI Number : 1811957871
Entity Type Code : Individual
Provider Name (Legal Business Name) : JON ANDREW SECREST PA
Provider Business Mailing Address
First Line : 2000 FRONTIS PLAZA BLVD STE 200
Second Line : (ATTN) FORSYTH MEDICAL GROUP
City : WINSTON SALEM
State : NC
Zip : 27103-5616
Country : US
Telephone Number : 336-277-2435
Fax Number : 336-277-9275
Provider Business Practice Location Address
First Line : 291 BROAD ST
Second Line : DBA KERNERSVILLE FAMILY PRACTICE
City : KERNERSVILLE
State : NC
Zip : 27284-2932
Country : US
Telephone Number : 336-993-8181
Fax Number : 336-996-9538
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2006
Last Update Date : 10/25/2020

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