Basic Information
Provider Information | |||||||||
NPI: | 1366715724 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAETTA | ||||||||
FirstName: | JILLIAN | ||||||||
MiddleName: | EILEEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUNTER | ||||||||
OtherFirstName: | JILLIAN | ||||||||
OtherMiddleName: | EILEEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 185 OLD COUNTRY RD | ||||||||
Address2: | SUITE 2 | ||||||||
City: | RIVERHEAD | ||||||||
State: | NY | ||||||||
PostalCode: | 119012121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312984479 | ||||||||
FaxNumber: | 6315913047 | ||||||||
Practice Location | |||||||||
Address1: | 64 COMMERCE AVE | ||||||||
Address2: |   | ||||||||
City: | RIVERHEAD | ||||||||
State: | NY | ||||||||
PostalCode: | 119014455 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6313695000 | ||||||||
FaxNumber: | 6315748773 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2012 | ||||||||
LastUpdateDate: | 01/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA22066 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 5893 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X | 5893 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0196942 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.