Provider Demographics
NPI:1366870347
Name:DE VERA, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:DE VERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W ELIZABETH ST APT A
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-4465
Mailing Address - Country:US
Mailing Address - Phone:443-562-7065
Mailing Address - Fax:
Practice Address - Street 1:417 W ELIZABETH ST APT A
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4465
Practice Address - Country:US
Practice Address - Phone:443-562-7065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12962174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist