Provider Demographics
NPI:1558649137
Name:MILLADO, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:MILLADO
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:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-707-1866
Mailing Address - Fax:215-707-1876
Practice Address - Street 1:100 E LEHIGH AVE
Practice Address - Street 2:CHC-1
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19125-1012
Practice Address - Country:US
Practice Address - Phone:215-707-1866
Practice Address - Fax:215-707-1876
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMA052478363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACD4829OtherRAILROAD MEDICARE GROUP
PA597586OtherMEDICARE GROUP