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General NPI Number Information
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NPI Number | 1518360536
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Entity Type | Individual
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Provider Name | JESSICA PETCHONKA PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/04/2014
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Last Update Date | 06/01/2020
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Provider Practice Location Address
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Address Line | 496 COUNTY ROAD 111 BUILDING B
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City | MANORVILLE
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State | NY
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Zip | 11949-3383
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Country | US
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Telephone | 631-405-3200
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Fax | 631-395-6010
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Provider Business Mailing Address
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Address Line | 185 OLD COUNTRY RD SUITE 2
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City | RIVERHEAD
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State | NY
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Zip | 11901-2121
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Country | US
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Telephone | 631-645-7017
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 018131
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License Number State | NY
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