Provider Demographics
NPI:1548625668
Name:CUNIGAN, JACQUELYN MARTIN (PA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARTIN
Last Name:CUNIGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACCQUELYN
Other - Middle Name:LEE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1115 BOULDERS PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:1115 BOULDERS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-4067
Practice Address - Country:US
Practice Address - Phone:804-320-1339
Practice Address - Fax:804-330-5829
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
VA0110005203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical