Provider Demographics
NPI:1629637350
Name:SIEGEL, JACQUELINE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:SIEGEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:305 E 40TH ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2156
Mailing Address - Country:US
Mailing Address - Phone:516-410-9950
Mailing Address - Fax:
Practice Address - Street 1:305 E 40TH ST APT 4D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2156
Practice Address - Country:US
Practice Address - Phone:516-410-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY024658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program