Basic Information
Provider Information | |||||||||
NPI: | 1023209368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEERY | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | ANDREW | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240111713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5402245715 | ||||||||
FaxNumber: | 5408575306 | ||||||||
Practice Location | |||||||||
Address1: | 2331 FRANKLIN RD SW | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240141111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407251226 | ||||||||
FaxNumber: | 5408575306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2007 | ||||||||
LastUpdateDate: | 09/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110002547 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X | 0110002547 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 1023209368 | 01 | VA | SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY | OTHER | 1023209368 | 01 | VA | AETNA | OTHER | 0123209368 | 01 | VA | MEDICAID QMB | OTHER | 1023209368 | 01 | VA | INTOTAL | OTHER | 1023209368 | 01 | VA | BLACK LUNG | OTHER | 540506332108 | 01 | VA | TRICARE/CHAMPUS | OTHER | P00831116 | 01 | VA | RAILROAD MEDICARE | OTHER | 1023209368 | 01 | VA | ANTHEM MEDIGAP | OTHER | 1023209368 | 01 | VA | CCC VA PREMIER | OTHER | 1023209368 | 01 | VA | HUMANA MEDICARE | OTHER | 1023209368 | 01 | VA | OPTIMA HEALTH PLAN | OTHER |