Provider Demographics
NPI:1851400428
Name:O'GORMAN, JAYNE LYN (RPA-C)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:LYN
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1704
Mailing Address - Country:US
Mailing Address - Phone:631-585-5858
Mailing Address - Fax:
Practice Address - Street 1:203 UNION AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1704
Practice Address - Country:US
Practice Address - Phone:631-585-5858
Practice Address - Fax:631-585-6362
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007576-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ36730Medicare UPIN