Healthcare Provider Details

I. General information

NPI: 1093054652
Provider Name (Legal Business Name): JACOB PUTKOWSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1368 N UNIVERSITY DR
PLANTATION FL
33322-4734
US

IV. Provider business mailing address

5229 N DIXIE HWY APT 29C2
OAKLAND PARK FL
33334-4028
US

V. Phone/Fax

Practice location:
  • Phone: 954-577-0001
  • Fax:
Mailing address:
  • Phone: 203-300-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107020
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027832
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: