Basic Information
| Provider Information | |||||||||
| NPI: | 1285055244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALAY | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159373433 | ||||||||
| FaxNumber: | 5853348732 | ||||||||
| Practice Location | |||||||||
| Address1: | 739 IRVING AVE STE 200-300 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154795070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 04169655 | 05 | NY | MEDICAID |