Provider Demographics
NPI:1861642159
Name:BALOGA, JACLYN (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BALOGA
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 1:1095 NW 14TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1060
Mailing Address - Country:US
Mailing Address - Phone:305-243-6946
Mailing Address - Fax:305-243-3337
Practice Address - Street 1:1095 NW 14TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1060
Practice Address - Country:US
Practice Address - Phone:305-243-6946
Practice Address - Fax:305-243-3337
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053542363AS0400X
NY014089363AS0400X
FLPA9107884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical