MEDICARE: STEPHEN J JACKOWSKI RPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	004417	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215990536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN J JACKOWSKI RPA

Provider Business Mailing Address
First Line	:	4103 MEDICAL CENTER DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-6600
Country	:	US
Telephone Number	:	315-637-7800
Fax Number	:	315-637-7808

Provider Business Practice Location Address
First Line	:	4103 MEDICAL CENTER DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-6600
Country	:	US
Telephone Number	:	315-637-7800
Fax Number	:	315-637-7808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	11/15/2011

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