Provider Demographics
NPI:1518360536
Name:PETCHONKA, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PETCHONKA
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 1:185 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2121
Mailing Address - Country:US
Mailing Address - Phone:631-645-7017
Mailing Address - Fax:
Practice Address - Street 1:496 COUNTY ROAD 111
Practice Address - Street 2:BUILDING B
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3383
Practice Address - Country:US
Practice Address - Phone:631-405-3200
Practice Address - Fax:631-395-6010
Is Sole Proprietor?:No
Enumeration Date:2014-10-04
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant