Provider Demographics
NPI:1396185609
Name:STUKAT GREN, JACLYN PAIGE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:PAIGE
Last Name:STUKAT GREN
Suffix:
Gender:F
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 WALL ST
Mailing Address - Street 2:34 FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-2836
Mailing Address - Country:US
Mailing Address - Phone:212-250-7753
Mailing Address - Fax:212-797-0808
Practice Address - Street 1:60 WALL ST
Practice Address - Street 2:34 FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-2836
Practice Address - Country:US
Practice Address - Phone:212-250-7753
Practice Address - Fax:212-797-0808
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053902363A00000X
NY018631-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant