Provider Demographics
NPI:1275509853
Name:MECKLING, JEFFREY G (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:G
Last Name:MECKLING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BELMONT AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-3498
Mailing Address - Country:US
Mailing Address - Phone:802-257-8360
Mailing Address - Fax:802-251-8435
Practice Address - Street 1:21 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7110
Practice Address - Country:US
Practice Address - Phone:802-258-3905
Practice Address - Fax:802-258-4903
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007856363A00000X
VT055-0031105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00007856Medicaid
NY02347597Medicaid
NY03046421Medicaid
VT9000529Medicaid
NYCC4774Medicare ID - Type Unspecified
NY331833Medicare Oscar/Certification
NYPA2603Medicare PIN
NY00007856Medicaid