Provider Demographics
NPI:1790457679
Name:KALARICKAL, JACOB JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOSEPH
Last Name:KALARICKAL
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 1:1210 WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-4208
Mailing Address - Country:US
Mailing Address - Phone:973-997-7258
Mailing Address - Fax:
Practice Address - Street 1:1210 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-4208
Practice Address - Country:US
Practice Address - Phone:646-612-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1610051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty