Provider Demographics
NPI:1083134803
Name:GARDUNO MORALES, JAZMIN (PA)
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:GARDUNO MORALES
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 1:10615 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11369-1924
Mailing Address - Country:US
Mailing Address - Phone:347-325-0925
Mailing Address - Fax:
Practice Address - Street 1:10615 29TH AVE
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11369-1924
Practice Address - Country:US
Practice Address - Phone:347-325-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021105363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant