Provider Demographics
NPI:1205469186
Name:PICKERAL, ROBERT JAMES JR (PAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:PICKERAL
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53-59 PUBLIC SQ STE 301
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2674
Mailing Address - Country:US
Mailing Address - Phone:315-786-8700
Mailing Address - Fax:315-782-5123
Practice Address - Street 1:53-59 PUBLIC SQ STE 301
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2674
Practice Address - Country:US
Practice Address - Phone:315-782-2141
Practice Address - Fax:315-782-5123
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024741363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024741OtherNEW YORK STATE