Provider Demographics
NPI:1154414100
Name:FAJARDO, DELINA (RPA-C)
Entity type:Individual
Prefix:
First Name:DELINA
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 MILITARY TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-310-3644
Mailing Address - Fax:578-310-3645
Practice Address - Street 1:1942 MILITARY TURNPIKE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-310-3644
Practice Address - Fax:578-310-3645
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00046000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ044574Medicare ID - Type Unspecified
NJP22006Medicare UPIN