Provider Demographics
NPI:1497977235
Name:HUMPHREY, JAY RALEIGH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:RALEIGH
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:8036 S TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5113
Practice Address - Country:US
Practice Address - Phone:941-244-4300
Practice Address - Fax:941-244-4380
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002111363A00000X
FLPA9116008363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant