Basic Information
| Provider Information | |||||||||
| NPI: | 1457324048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLERT | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 ROUTE 59 | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109014927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453575775 | ||||||||
| FaxNumber: | 8453575777 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109014812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453685039 | ||||||||
| FaxNumber: | 8453685327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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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 | 207L00000X | 25MA07996300 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 243789 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02868931 | 05 | NY | MEDICAID | 0085774 | 05 | NY | MEDICAID | P00601586 | 01 | NY | RAILROAD MEDICARE | OTHER |