Provider Demographics
NPI:1164969333
Name:RAZEQ, JENNA MARAE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARAE
Last Name:RAZEQ
Suffix:
Gender:F
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 1:72 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-3929
Mailing Address - Country:US
Mailing Address - Phone:516-225-5151
Mailing Address - Fax:
Practice Address - Street 1:1000 N VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1000
Practice Address - Country:US
Practice Address - Phone:516-705-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant