Provider Demographics
NPI:1760631279
Name:BOHANKO, JACQUELINE KALIS (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KALIS
Last Name:BOHANKO
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 1:2099 NEW ALBANY RD
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3534
Mailing Address - Country:US
Mailing Address - Phone:609-926-8899
Mailing Address - Fax:856-772-1997
Practice Address - Street 1:2099 NEW ALBANY RD
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3534
Practice Address - Country:US
Practice Address - Phone:099-268-8996
Practice Address - Fax:856-772-1997
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00879200363A00000X
PAMA053571363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant