=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962896944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY KLIMAR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2015
-----------------------------------------------------
Last Update Date | 03/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 JESSE CT
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-2139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-775-9297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 JESSE CT
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-2139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 017291
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------