Provider Demographics
NPI:1801106315
Name:AMARU, JACLYN NOELLE (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NOELLE
Last Name:AMARU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:NOELLE
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MERRICK RD STE 128W
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4821
Mailing Address - Country:US
Mailing Address - Phone:516-255-9031
Mailing Address - Fax:
Practice Address - Street 1:100 MERRICK RD STE 128W
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4821
Practice Address - Country:US
Practice Address - Phone:516-255-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0141421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant