Provider Demographics
NPI:1245476605
Name:WANG, JENNIFER EILEEN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EILEEN
Last Name:WANG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2407
Mailing Address - Country:US
Mailing Address - Phone:718-920-6136
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:10467-2407
Practice Address - Country:US
Practice Address - Phone:718-920-6136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006036-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant