Provider Demographics
NPI:1992581532
Name:DEVIVO, JO BAYLISS (PA-C)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:BAYLISS
Last Name:DEVIVO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JO
Other - Middle Name:BAYLISS
Other - Last Name:BASLOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11107 ROCK GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4935
Mailing Address - Country:US
Mailing Address - Phone:843-618-8457
Mailing Address - Fax:
Practice Address - Street 1:163 THOMAS JOHNSON DR STE H
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4673
Practice Address - Country:US
Practice Address - Phone:301-694-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant