Provider Demographics
NPI:1831163120
Name:SICA, JERRY A (PA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:A
Last Name:SICA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MANSION AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3504
Mailing Address - Country:US
Mailing Address - Phone:718-605-4085
Mailing Address - Fax:718-331-3871
Practice Address - Street 1:1407 W 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4802
Practice Address - Country:US
Practice Address - Phone:718-236-6994
Practice Address - Fax:718-331-3871
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005358363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005358OtherSTATE LICENSE
NY01981057Medicaid
NY01981057Medicaid