1235464983 NPI number — MR. RICHARD PAUL JASKEWICH PHYSCIAN ASSISTANT

Table of content: MR. RICHARD PAUL JASKEWICH PHYSCIAN ASSISTANT (NPI 1235464983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235464983 NPI number — MR. RICHARD PAUL JASKEWICH PHYSCIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JASKEWICH
Provider First Name:
RICHARD
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSCIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235464983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5409 DELRAY DRIVE
Provider Second Line Business Mailing Address:
FAIRWAY FALLS
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-454-7928
Provider Business Mailing Address Fax Number:
302-454-7928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-369-3533
Provider Business Practice Location Address Fax Number:
302-369-3093
Provider Enumeration Date:
10/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C50000126 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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