Provider Demographics
NPI:1588492466
Name:MATTONE, JACQUELINE IRENE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:IRENE
Last Name:MATTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53A S BAY AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11941-1345
Mailing Address - Country:US
Mailing Address - Phone:718-938-5833
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant