Provider Demographics
NPI:1093054652
Name:PUTKOWSKI, JACOB (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:PUTKOWSKI
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 1:5229 N DIXIE HWY
Mailing Address - Street 2:APT 29C2
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4028
Mailing Address - Country:US
Mailing Address - Phone:203-300-9224
Mailing Address - Fax:
Practice Address - Street 1:1368 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4734
Practice Address - Country:US
Practice Address - Phone:954-577-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107020363A00000X
NY027832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant