Provider Demographics
NPI:1528310216
Name:JEAN, ASTRID THALIA (PA)
Entity type:Individual
Prefix:MRS
First Name:ASTRID
Middle Name:THALIA
Last Name:JEAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ASTRID
Other - Middle Name:THALIA
Other - Last Name:LOUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3411 WAYNE AVE
Mailing Address - Street 2:APT 8L
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2509
Mailing Address - Country:US
Mailing Address - Phone:347-879-5978
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015363363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical