Provider Demographics
NPI:1740362516
Name:KACZMARSKI, JARRETT PETER (PA)
Entity type:Individual
Prefix:MR
First Name:JARRETT
Middle Name:PETER
Last Name:KACZMARSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 48TH ST APT 7N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-1147
Mailing Address - Country:US
Mailing Address - Phone:917-687-2381
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:MLK RM 3101A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0084761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical