Provider Demographics
NPI:1043054158
Name:MIR, JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MIR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 HILTONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-8207
Mailing Address - Country:US
Mailing Address - Phone:315-391-6094
Mailing Address - Fax:
Practice Address - Street 1:7375 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3717
Practice Address - Country:US
Practice Address - Phone:315-291-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty