Provider Demographics
NPI:1558396127
Name:CONENNA, JENNIFER ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:CONENNA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:GIGANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 ASTOR AVE
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5900
Mailing Address - Country:US
Mailing Address - Phone:718-652-0003
Mailing Address - Fax:347-843-7841
Practice Address - Street 1:1500 ASTOR AVE
Practice Address - Street 2:SUITE 1E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5900
Practice Address - Country:US
Practice Address - Phone:718-652-0003
Practice Address - Fax:347-843-7841
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18210363A00000X
NY010884363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ67897Medicare UPIN