Provider Demographics
NPI:1023021706
Name:CUNNINGHAM, JILL W (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:W
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:WALDRAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:615 CHESTNUT ST
Mailing Address - Street 2:14TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4404
Mailing Address - Country:US
Mailing Address - Phone:215-955-9655
Mailing Address - Fax:215-955-2420
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-551-8660
Practice Address - Fax:215-551-9247
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA081712Medicare PIN
PAQ20933Medicare UPIN