Provider Demographics
NPI:1679643852
Name:EISEN, JODI A (PA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:A
Last Name:EISEN
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 1:4160 HUTCHINSON RIVER PKWY E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-4832
Mailing Address - Country:US
Mailing Address - Phone:718-920-4058
Mailing Address - Fax:718-798-0730
Practice Address - Street 1:MMC - EMERGENCY MEDICINE
Practice Address - Street 2:111 EAST 210TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant