Provider Demographics
NPI:1043338585
Name:NIZNIKIEWICZ, JENNIFER MARIA (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIA
Last Name:NIZNIKIEWICZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:MARIA
Other - Last Name:ELROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:259 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3957
Mailing Address - Country:US
Mailing Address - Phone:516-663-8700
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP93293Medicare UPIN