Provider Demographics
NPI:1598763054
Name:FARRES, JENNIFER ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:FARRES
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 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2090
Mailing Address - Fax:
Practice Address - Street 1:2001 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1215
Practice Address - Country:US
Practice Address - Phone:704-323-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103568363A00000X
NC28417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC126P3OtherBLUE CROSS BLUE SHIELD
37994OtherPARTNERS MEDICARE
NC89126P3Medicaid
37994OtherPARTNERS MEDICARE
SCAA38346191Medicare PIN
NC89126P3Medicaid
NC2756783Medicare PIN