Provider Demographics
NPI:1659346427
Name:SULKOW, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SULKOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3791
Mailing Address - Country:US
Mailing Address - Phone:518-482-9111
Mailing Address - Fax:518-482-6142
Practice Address - Street 1:6 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3791
Practice Address - Country:US
Practice Address - Phone:518-482-9111
Practice Address - Fax:518-482-6142
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4879021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000499324001OtherBLUE SHIELD OF NORTHEASTE
NY4123605OtherMOHAWK VALLEY PHYSICIANS
NYCC5600Medicare UPIN
NY33680AMedicare ID - Type Unspecified