Provider Demographics
NPI:1578930731
Name:FIFE, JARED K (PA)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:K
Last Name:FIFE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5414 MERLIN WAY
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5658
Mailing Address - Country:US
Mailing Address - Phone:208-740-9266
Mailing Address - Fax:
Practice Address - Street 1:4601 SPANISH TRL
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5039
Practice Address - Country:US
Practice Address - Phone:850-850-7589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9491002-1206363AM0700X
CA54155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical