Provider Demographics
NPI:1316338361
Name:STAFFORD, JESSE A (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:A
Last Name:STAFFORD
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 735
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AR
Mailing Address - Zip Code:72722-0735
Mailing Address - Country:US
Mailing Address - Phone:479-752-3233
Mailing Address - Fax:479-752-3235
Practice Address - Street 1:346 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AR
Practice Address - Zip Code:72722-9732
Practice Address - Country:US
Practice Address - Phone:479-752-3233
Practice Address - Fax:479-752-3235
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-598363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical