Basic Information
| Provider Information | |||||||||
| NPI: | 1659430205 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | COTGREAVE | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT OF MED/CARDIOLOGY HSC T16-080 | ||||||||
| Address2: | STONY BROOK UNIVERSITY | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441106 | ||||||||
| FaxNumber: | 6314442493 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPARTMENT OF MED/CARDIOLOGY HSC T16-080 | ||||||||
| Address2: | STONY BROOK UNIVERSITY | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441106 | ||||||||
| FaxNumber: | 6314442493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010753 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.