Provider Demographics
NPI:1144508177
Name:DAVIS, JENNIFER T (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:99 E STATE ST
Mailing Address - Street 2:PO BOX 1250
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1203
Mailing Address - Country:US
Mailing Address - Phone:518-773-5690
Mailing Address - Fax:518-773-5620
Practice Address - Street 1:99 E STATE ST
Practice Address - Street 2:MAB-GPCC
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1203
Practice Address - Country:US
Practice Address - Phone:518-773-5690
Practice Address - Fax:518-773-5620
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2015-01-21
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400086254Medicare PIN