Provider Demographics
NPI:1295843852
Name:REDDING, JACK E II (PA-C)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:REDDING
Suffix:II
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 1:60 MARTINS HILL RD
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-2809
Mailing Address - Country:US
Mailing Address - Phone:518-694-2965
Mailing Address - Fax:
Practice Address - Street 1:11835 RT 9W
Practice Address - Street 2:
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192-3605
Practice Address - Country:US
Practice Address - Phone:518-731-9000
Practice Address - Fax:518-731-9119
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100926363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS92696Medicare UPIN
FLE3271ZMedicare ID - Type Unspecified