Provider Demographics
NPI:1043644719
Name:CONMEY, JESSICA KRISTINE (PA- C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KRISTINE
Last Name:CONMEY
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 W GRAND AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2010
Mailing Address - Country:US
Mailing Address - Phone:262-536-4344
Mailing Address - Fax:262-536-4348
Practice Address - Street 1:1329 W GRAND AVE STE 4
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2010
Practice Address - Country:US
Practice Address - Phone:262-536-4344
Practice Address - Fax:262-536-4348
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3215-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400214502Medicare PIN