Healthcare Provider Details

I. General information

NPI: 1295843852
Provider Name (Legal Business Name): JACK E. REDDING II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 RT 9W
WEST COXSACKIE NY
12192-3605
US

IV. Provider business mailing address

60 MARTINS HILL RD
RAVENA NY
12143-2809
US

V. Phone/Fax

Practice location:
  • Phone: 518-731-9000
  • Fax: 518-731-9119
Mailing address:
  • Phone: 518-694-2965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9100926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: