Provider Demographics
NPI:1245395318
Name:LUSTIG, JACLYN (PAC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:LUSTIG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:95 HIGHLAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-9424
Mailing Address - Country:US
Mailing Address - Phone:610-868-1100
Mailing Address - Fax:610-868-1111
Practice Address - Street 1:95 HIGHLAND AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-9424
Practice Address - Country:US
Practice Address - Phone:610-868-1100
Practice Address - Fax:610-868-1111
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052882363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA386881Medicare PIN