Provider Demographics
NPI:1326451337
Name:MOHADEB, JACK (PA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:MOHADEB
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 1:1977 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3307
Mailing Address - Country:US
Mailing Address - Phone:917-751-6126
Mailing Address - Fax:
Practice Address - Street 1:1977 E 15TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3307
Practice Address - Country:US
Practice Address - Phone:917-751-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014776-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014776-1OtherLICENSE#