Provider Demographics
NPI:1467431866
Name:MOTSIFF, JEROY S (PNP)
Entity Type:Individual
Prefix:MRS
First Name:JEROY
Middle Name:S
Last Name:MOTSIFF
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:BUSKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:12028-2521
Mailing Address - Country:US
Mailing Address - Phone:518-677-3597
Mailing Address - Fax:
Practice Address - Street 1:33 GILBERT ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-2643
Practice Address - Country:US
Practice Address - Phone:518-677-8575
Practice Address - Fax:518-677-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380744363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01614819Medicaid