Healthcare Provider Details

I. General information

NPI: 1720760218
Provider Name (Legal Business Name): JACOB TYLER DEUBLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

14 WALL ST FL 9
NEW YORK NY
10005-2178
US

V. Phone/Fax

Practice location:
  • Phone: 540-287-6371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number031046
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: