Provider Demographics
NPI:1548719065
Name:DEVIRGILIS, JARED (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:DEVIRGILIS
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 1:367 S. GULPH RD
Mailing Address - Street 2:ATTN: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:941-746-5111
Mailing Address - Fax:
Practice Address - Street 1:206 2ND ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1042
Practice Address - Country:US
Practice Address - Phone:941-746-5111
Practice Address - Fax:941-745-7233
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9109796363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical