Provider Demographics
NPI:1356606800
Name:MCQUADE, JACLYN DANIELLE (RPA-C)
Entity type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:DANIELLE
Last Name:MCQUADE
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 1:14 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4321
Mailing Address - Country:US
Mailing Address - Phone:631-487-6539
Mailing Address - Fax:
Practice Address - Street 1:1171 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5022
Practice Address - Country:US
Practice Address - Phone:516-931-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03789273Medicaid