Provider Demographics
NPI:1659430205
Name:COTGREAVE, JACLYN N (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:N
Last Name:COTGREAVE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:DEPARTMENT OF MED/CARDIOLOGY HSC T16-080
Mailing Address - Street 2:STONY BROOK UNIVERSITY
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-1106
Mailing Address - Fax:631-444-2493
Practice Address - Street 1:DEPARTMENT OF MED/CARDIOLOGY HSC T16-080
Practice Address - Street 2:STONY BROOK UNIVERSITY
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-1106
Practice Address - Fax:631-444-2493
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2014-03-13
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Provider Licenses
StateLicense IDTaxonomies
NY010753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant