Provider Demographics
NPI:1083733869
Name:JOHN, SIJI MARY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:SIJI
Middle Name:MARY
Last Name:JOHN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 -11 251 ST
Mailing Address - Street 2:85-11
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2127
Mailing Address - Country:US
Mailing Address - Phone:718-776-8342
Mailing Address - Fax:
Practice Address - Street 1:501 S 54TH ST
Practice Address - Street 2:MERCY GASTROENTEROLOGY ASSOCIATES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011428363A00000X
PAMA054486363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical