Provider Demographics
NPI:1992806772
Name:BAHROS, JESSICA LEE (PAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:BAHROS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SCOBEE CIR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SCOBEE CIR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4887
Practice Address - Country:US
Practice Address - Phone:508-747-0711
Practice Address - Fax:508-746-9265
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP0995Medicare ID - Type Unspecified
S74104Medicare UPIN