Provider Demographics
NPI:1952721110
Name:REHAN, JACQUELINE MICHELLE (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:REHAN
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 MINEOLA AVE 200
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2042
Mailing Address - Country:US
Mailing Address - Phone:516-616-5500
Mailing Address - Fax:888-502-6582
Practice Address - Street 1:3003 NEW HYDE PARK RD
Practice Address - Street 2:SUITE #307
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1206
Practice Address - Country:US
Practice Address - Phone:516-616-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017491363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical