Basic Information
| Provider Information | |||||||||
| NPI: | 1609986280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELL | ||||||||
| FirstName: | JAMIE LEA | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 4TH AVE | ||||||||
| Address2: | PO BOX 336 | ||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Practice Location | |||||||||
| Address1: | 11134 N STATE ROAD 77 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548435325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156345505 | ||||||||
| FaxNumber: | 7156345558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1334 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1334-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 41924600 | 05 | WI | MEDICAID |