Basic Information
| Provider Information | |||||||||
| NPI: | 1174818884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | JERROLD | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36000 DARNALL LOOP | ||||||||
| Address2: | CARL R. DARNALL ARMY MEDICAL CENTER | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765444752 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 36000 DARNALL LOOP | ||||||||
| Address2: | CARL R. DARNALL ARMY MEDICAL CENTER | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765444752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 06/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.