Provider Demographics
NPI:1558786491
Name:ELLNER, JENNIFER (PA-C, MPAS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ELLNER
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3957
Mailing Address - Country:US
Mailing Address - Phone:516-663-8312
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-8312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-01
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23017431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant