Healthcare Provider Details

I. General information

NPI: 1780779009
Provider Name (Legal Business Name): JENNIFER MCCANN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ROUTE 25A SUITE C
SHOREHAM NY
11786-1389
US

IV. Provider business mailing address

45 ROUTE 25A SUITE C
SHOREHAM NY
11786-1389
US

V. Phone/Fax

Practice location:
  • Phone: 631-744-3303
  • Fax: 631-744-1627
Mailing address:
  • Phone: 631-744-3303
  • Fax: 631-744-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: