Individual
JERROLD PAUL ELLIOTT III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
16319 THIRD STREET, GUERNEVILLE, CA 95446
(707) 869-5977
(707) 869-5983
Mailing address
PO BOX 1449, GUERNEVILLE, CA 95446-1449
(707) 869-5977
(707) 869-5983
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
2666
CO
363AM0700X
Medical Physician Assistant
Primary
PA20527
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1356344758
—
CA
Enumeration date
09/30/2008
Last updated
01/25/2021
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