Provider Demographics
NPI:1053782946
Name:ARCHER, JOHN BRIAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRIAN
Last Name:ARCHER
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 1:4949 W 227TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2412
Mailing Address - Country:US
Mailing Address - Phone:440-241-4313
Mailing Address - Fax:
Practice Address - Street 1:6847 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-17
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004486363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant