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General NPI Number Information
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NPI Number | 1881299352
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Entity Type | Individual
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Provider Name | DAVID BRUCE JACK JR. PA
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Gender | Male
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Dates
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Enumeration Date | 12/02/2020
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Last Update Date | 12/02/2020
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Provider Practice Location Address
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Address Line | 281 1ST AVE
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City | NEW YORK
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State | NY
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Zip | 10003-2925
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Country | US
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Telephone | 212-420-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 214 PINE RD
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City | CORAM
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State | NY
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Zip | 11727-2410
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Country | US
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Telephone |
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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 | 025760
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License Number State | NY
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