Provider Demographics
NPI:1366773202
Name:SOARES, JEFFREY MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:SOARES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 FAUNCE CORNER MALL RD
Mailing Address - Street 2:DERMATOLOGY SERVICES
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747
Mailing Address - Country:US
Mailing Address - Phone:508-993-7601
Mailing Address - Fax:508-997-0523
Practice Address - Street 1:145 FAUNCE CORNER MALL RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-6216
Practice Address - Country:US
Practice Address - Phone:508-993-7601
Practice Address - Fax:508-997-0523
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001487201Medicare PIN