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General NPI Number Information
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NPI Number | 1902447766
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Entity Type | Individual
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Provider Name | JENNA GOTTLIEB PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/03/2019
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Last Update Date | 01/17/2021
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Provider Practice Location Address
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Address Line | 1901 1ST AVE
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City | NEW YORK
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State | NY
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Zip | 10029-7491
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Country | US
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Telephone | 631-275-9695
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Fax |
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Provider Business Mailing Address
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Address Line | 1901 1ST AVE
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City | NEW YORK
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State | NY
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Zip | 10029-7494
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Country | US
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Telephone | 212-423-6416
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 024214
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License Number State | NY
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