Provider Demographics
NPI:1871354431
Name:ROTTKAMP, JENNIFER MICHELE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:ROTTKAMP
Suffix:
Gender:F
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 1:100 NICOLLS ROAD, HSC T12, ROOM 080
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8122
Mailing Address - Country:US
Mailing Address - Phone:631-444-1213
Mailing Address - Fax:631-444-1535
Practice Address - Street 1:100 NICOLLS ROAD, HSC T12, ROOM 080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8122
Practice Address - Country:US
Practice Address - Phone:631-444-1213
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant