MEDICARE: JACOB WOLFSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	019838	NY

General Provider Information

NPI Number	:	1376095430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB WOLFSON PA-C

Provider Business Mailing Address
First Line	:	55 E 87TH ST
Second Line	:	1G
City	:	NEW YORK
State	:	NY
Zip	:	10128-1043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 E 57TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-2822
Country	:	US
Telephone Number	:	212-686-6321
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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