Provider Demographics
NPI:1679695860
Name:KEAT-WYSOCKI, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KEAT-WYSOCKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KEAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 8500-1611
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 BRUNSWICK AVE
Practice Address - Street 2:CAPITAL HEALTH TRAUMA DEPARTMENT
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4143
Practice Address - Country:US
Practice Address - Phone:609-394-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00089000363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ059726M5NMedicare PIN