Provider Demographics
NPI:1205138419
Name:STALL, JENNIFER MICHELE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:STALL
Suffix:
Gender:F
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 1:30 BEALE RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-2901
Mailing Address - Country:US
Mailing Address - Phone:518-392-4869
Mailing Address - Fax:
Practice Address - Street 1:11835 STATE ROUTE 9W
Practice Address - Street 2:EMURGENT CARE
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192-3605
Practice Address - Country:US
Practice Address - Phone:518-731-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MA862889146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic