Provider Demographics
NPI:1952457772
Name:HEINERICH, JEREMY TODD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:TODD
Last Name:HEINERICH
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 1:430 E 20TH ST APT 8H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-8205
Mailing Address - Country:US
Mailing Address - Phone:917-991-5975
Mailing Address - Fax:
Practice Address - Street 1:1470 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6542
Practice Address - Country:US
Practice Address - Phone:917-991-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011084363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP25038Medicare UPIN