Healthcare Provider Details

I. General information

NPI: 1073022497
Provider Name (Legal Business Name): JENNIFER MINCHAO REN-HOLZMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-5237
  • Fax: 860-714-8097
Mailing address:
  • Phone: 860-714-5237
  • Fax: 860-714-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.003983
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: