Provider Demographics
NPI:1346278983
Name:BINGHAM, JENNIFER C (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:C
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:CONSTANTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:53 ORCHARD ST
Mailing Address - Street 2:UNIT #1
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:917-683-7742
Mailing Address - Fax:
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:9TH FLOOR, BOX 1188
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-0735
Practice Address - Fax:212-241-0735
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009786-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ14592Medicare UPIN
NYPA1320Medicare ID - Type UnspecifiedIND. # FOR GROUP