Provider Demographics
NPI:1205850591
Name:FUQUA, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FUQUA
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 1:1 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-3245
Mailing Address - Fax:336-716-0567
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-3208
Practice Address - Country:US
Practice Address - Phone:336-716-3245
Practice Address - Fax:336-716-0567
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102054363AM0700X
FLPA 9102758363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC102054OtherPA LICENSE NUMBER
NC102054OtherPA LICENSE NUMBER