Healthcare Provider Details

I. General information

NPI: 1588761662
Provider Name (Legal Business Name): ADAM E JACOBSEN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 IRVING AVE STE 640
SYRACUSE NY
13210
US

IV. Provider business mailing address

251 SALINA MEADOWS PKWY STE 100
SYRACUSE NY
13212-4516
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-6255
  • Fax: 315-464-6251
Mailing address:
  • Phone: 315-464-2000
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008124
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number008124
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: