Healthcare Provider Details

I. General information

NPI: 1841702396
Provider Name (Legal Business Name): JESSICA CUPOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W 37TH ST FL 4
NEW YORK NY
10018-4228
US

IV. Provider business mailing address

306 W 48TH ST APT 24A
NEW YORK NY
10036-1385
US

V. Phone/Fax

Practice location:
  • Phone: 212-465-8304
  • Fax:
Mailing address:
  • Phone: 516-852-8769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number021561
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: