Provider Demographics
NPI:1316076466
Name:TRIPLETT, JOHN JAY JR (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAY
Last Name:TRIPLETT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 STONEBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27313-8226
Mailing Address - Country:US
Mailing Address - Phone:336-641-3254
Mailing Address - Fax:
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZA0000006Medicaid