MEDICARE: MRS. JENNIFER ANN CONENNA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA18210	CA
2	363AS0400X	Surgical Physician Assistant	010884	NY
3	363A00000X	Physician Assistant	010884	NY

General Provider Information

NPI Number	:	1558396127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER ANN CONENNA PA

Provider Business Mailing Address
First Line	:	1500 ASTOR AVE
Second Line	:	SUITE 1E
City	:	BRONX
State	:	NY
Zip	:	10469-5900
Country	:	US
Telephone Number	:	718-652-0003
Fax Number	:	347-843-7841

Provider Business Practice Location Address
First Line	:	1500 ASTOR AVE
Second Line	:	SUITE 1E
City	:	BRONX
State	:	NY
Zip	:	10469-5900
Country	:	US
Telephone Number	:	718-652-0003
Fax Number	:	347-843-7841

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	01/18/2010

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