Provider Demographics
NPI:1386097723
Name:SWANSON, JAIME (PA)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:3271 CLEAR VISTA CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9477
Practice Address - Country:US
Practice Address - Phone:616-267-7293
Practice Address - Fax:616-267-9594
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-08584363A00000X
MI5601007855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant