Provider Demographics
NPI:1598746513
Name:FLAHERTY, JENNIFER A (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:FLAHERTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 FULTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:612-672-7100
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-672-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10917363AS0400X
WI1874023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1598746513Medicaid
WI42872100Medicaid
WI42872100Medicaid