Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | MT200630 | PA |
NPI | 1013295674 |
---|---|
Provider Name | Andrew Jacques |
First Address | Hershey, PA 17033-2360 |
Second Address | Hershey, PA 17033-2360 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2011 |
Last Update Date | 01/08/2011 |