Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Mr. Shane Saji Jacob, PA

Individual provider Physician Assistant · NPI 1609484468

Mr. Shane Saji Jacob, PA is a Physician Assistant in Elmhurst, New York. Qualified in 2020, 6 years ago. Practices with Divinity Medical Services PLLC, a 93-clinician group and accepts Medicare assignment. Licensed in New York.

Years since qualifying
6
Licensed in
NY
In the registry since
2020
Specialties on file
2
What do these letters mean?
PA — Physician Assistant
A licensed clinician who examines, diagnoses and treats under a physician's supervision.

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Practice location Address checks out

7901 Broadway
Elmhurst, NY 11373-1329
Phone: (718) 334-2480
Fax: (718) 334-2478
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X · Licence 025732 (NY)
Physician Assistant Taxonomy 363A00000X

Record details

NPI number1609484468
Entity typeIndividual (Type 1)
GenderMale
Credentials PA
Sole proprietorNo
NPI enumeratedJuly 17, 2020
Last updated in NPPESFebruary 26, 2021
Certification dateFebruary 26, 2021

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2020 (6 years in practice)
Group practice Divinity Medical Services Pllc — 93 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations6 on file with Medicare

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