Healthcare Provider Details

I. General information

NPI: 1497806301
Provider Name (Legal Business Name): CONNIE JARDINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 POST ST SUITE 107
SAN FRANCISCO CA
94115-3441
US

IV. Provider business mailing address

2299 POST ST SUITE 107
SAN FRANCISCO CA
94115-3441
US

V. Phone/Fax

Practice location:
  • Phone: 415-345-9400
  • Fax: 415-345-8049
Mailing address:
  • Phone: 415-345-9400
  • Fax: 415-345-8049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number12496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: