Provider Demographics
NPI:1063441517
Name:ETTINGER, JACOB HENRY (PA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:HENRY
Last Name:ETTINGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:21 CANTERBURY RD
Mailing Address - Street 2:APARTMENT #3
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2123
Mailing Address - Country:US
Mailing Address - Phone:516-570-6015
Mailing Address - Fax:
Practice Address - Street 1:21 CANTERBURY RD
Practice Address - Street 2:APARTMENT #3
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2123
Practice Address - Country:US
Practice Address - Phone:516-570-6015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009528363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical