Healthcare Provider Details

I. General information

NPI: 1508835992
Provider Name (Legal Business Name): JEFFREY LOUIS AVERY PAC, MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 VESTAL PKWY E
VESTAL NY
13850-3556
US

IV. Provider business mailing address

33 LEWIS RD STE 2
BINGHAMTON NY
13905-1040
US

V. Phone/Fax

Practice location:
  • Phone: 607-771-2220
  • Fax: 607-251-2635
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA003068L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007379-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: