Provider Demographics
NPI:1568891372
Name:SOMMER, JEREMY (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:SOMMER
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 1:1550 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1510
Mailing Address - Country:US
Mailing Address - Phone:718-698-1616
Mailing Address - Fax:
Practice Address - Street 1:1550 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1510
Practice Address - Country:US
Practice Address - Phone:718-698-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant