Provider Demographics
NPI:1497764229
Name:OPFERMAN, JENNIFER TATE (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TATE
Last Name:OPFERMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BETH
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-747-5800
Mailing Address - Fax:360-575-3846
Practice Address - Street 1:1718 E KESSLER BLVD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1842
Practice Address - Country:US
Practice Address - Phone:360-747-5800
Practice Address - Fax:360-575-3846
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8942375OtherCRIME VICTIMS WA STATE
P00341341OtherRR MEDICARE
WA0212503OtherLABOR & IND. WA STATE
WA8461782Medicaid
WA8461782Medicaid
WA8861699Medicare PIN