Provider Demographics
NPI:1639549108
Name:NIEWIADOMSKI, JENNIFER DEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DEAN
Last Name:NIEWIADOMSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-795-4049
Mailing Address - Fax:513-354-7651
Practice Address - Street 1:1313 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3120
Practice Address - Country:US
Practice Address - Phone:614-890-6555
Practice Address - Fax:614-823-8881
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.004437363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0145495Medicaid
OHH465660OtherMEDICARE PTAN