Provider Demographics
NPI:1215057682
Name:SCRIVER, JON MACKAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:MACKAY
Last Name:SCRIVER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2418 E HIGHWAY 66 # 226
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4767
Mailing Address - Country:US
Mailing Address - Phone:210-373-9479
Mailing Address - Fax:
Practice Address - Street 1:15556 OLMSTED PL
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-6606
Practice Address - Country:US
Practice Address - Phone:210-373-9479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04206363AM0700X
COPA.0003901363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical