Basic Information
| Provider Information | |||||||||
| NPI: | 1649508763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | JEREMIAH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3082 MCMURRAY DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960073544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303654420 | ||||||||
| FaxNumber: | 5303655186 | ||||||||
| Practice Location | |||||||||
| Address1: | 5974 PENTZ RD | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959695509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308779361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2009 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19056 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.