Provider Demographics
NPI:1326228701
Name:COMBES, JACLYN R (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:R
Last Name:COMBES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:R
Other - Last Name:MASTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:128 BOYNTON AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-324-3399
Mailing Address - Fax:518-324-3396
Practice Address - Street 1:128 BOYNTON AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-324-3399
Practice Address - Fax:518-324-3396
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011596363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14-1785867OtherETIN