Provider Demographics
NPI:1588785745
Name:SAMUEL, JINI (RPA-C)
Entity type:Individual
Prefix:MRS
First Name:JINI
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:JINI
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 DUKE PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5119
Mailing Address - Country:US
Mailing Address - Phone:718-494-2599
Mailing Address - Fax:
Practice Address - Street 1:462 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-9196
Practice Address - Country:US
Practice Address - Phone:212-562-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007227-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical