Provider Demographics
NPI:1083133664
Name:JAHRA, FATEMA (PA)
Entity Type:Individual
Prefix:
First Name:FATEMA
Middle Name:
Last Name:JAHRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9608 57TH AVE APT 5M
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3403
Mailing Address - Country:US
Mailing Address - Phone:929-346-2440
Mailing Address - Fax:
Practice Address - Street 1:130 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1851
Practice Address - Country:US
Practice Address - Phone:212-434-3900
Practice Address - Fax:212-434-3899
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant