Provider Demographics
NPI:1548859069
Name:SPATAFORA, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:SPATAFORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 HALF HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1022
Mailing Address - Country:US
Mailing Address - Phone:631-860-3024
Mailing Address - Fax:
Practice Address - Street 1:527 HALF HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-1022
Practice Address - Country:US
Practice Address - Phone:631-860-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant