Provider Demographics
NPI:1902989205
Name:MCREAVY, JERRY (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MCREAVY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-0236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N 5TH ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-1480
Practice Address - Country:US
Practice Address - Phone:605-747-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant