Provider Demographics
NPI:1497806301
Name:JARDINE, CONNIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:JARDINE
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 1:2299 POST ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3441
Mailing Address - Country:US
Mailing Address - Phone:415-345-9400
Mailing Address - Fax:415-345-8049
Practice Address - Street 1:2299 POST ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3441
Practice Address - Country:US
Practice Address - Phone:415-345-9400
Practice Address - Fax:415-345-8049
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12496363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12496OtherPHYSICIAN ASSISTANT NUMBE