Provider Demographics
NPI:1376095430
Name:WOLFSON, JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WOLFSON
Suffix:
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 1:55 E 87TH ST
Mailing Address - Street 2:1G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 E 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2822
Practice Address - Country:US
Practice Address - Phone:212-686-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant