Healthcare Provider Details

I. General information

NPI: 1760631279
Provider Name (Legal Business Name): JACQUELINE KALIS BOHANKO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2099 NEW ALBANY RD
CINNAMINSON NJ
08077-3534
US

IV. Provider business mailing address

2099 NEW ALBANY RD
CINNAMINSON NJ
08077-3534
US

V. Phone/Fax

Practice location:
  • Phone: 99-268-8996
  • Fax: 856-772-1997
Mailing address:
  • Phone: 609-926-8899
  • Fax: 856-772-1997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00879200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053571
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: