Basic Information
| Provider Information | |||||||||
| NPI: | 1205138419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BEALE RD | ||||||||
| Address2: | |||||||||
| City: | CHATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120372901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183924869 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11835 STATE ROUTE 9W | ||||||||
| Address2: | EMURGENT CARE | ||||||||
| City: | WEST COXSACKIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121923605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187319000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2010 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 146L00000X | 862889 | MA | N | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |
No ID Information.