Healthcare Provider Details

I. General information

NPI: 1376102657
Provider Name (Legal Business Name): KIANA JEFFERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 5TH AVE FL 3
NEW YORK NY
10017-6145
US

IV. Provider business mailing address

129 W 29TH ST FL 10
NEW YORK NY
10001-5105
US

V. Phone/Fax

Practice location:
  • Phone: 212-441-4400
  • Fax: 212-867-4353
Mailing address:
  • Phone: 415-658-6791
  • Fax: 415-520-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024439
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number024439
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: