Provider Demographics
NPI:1932499464
Name:BOADO, JESSICA (RPA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOADO
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:PO BOX 95000-6625
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-6625
Mailing Address - Country:US
Mailing Address - Phone:631-465-6297
Mailing Address - Fax:631-465-6524
Practice Address - Street 1:1703 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1628
Practice Address - Country:US
Practice Address - Phone:516-378-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014722-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant