Basic Information
| Provider Information | |||||||||
| NPI: | 1003927633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYER | ||||||||
| FirstName: | JEROMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 973 MICA DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897057255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757836190 | ||||||||
| FaxNumber: | 7757836191 | ||||||||
| Practice Location | |||||||||
| Address1: | 973 MICA DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897057255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757836190 | ||||||||
| FaxNumber: | 7757836191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0335 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA15875 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0PA158750 | 05 | CA | MEDICAID |