Provider Demographics
NPI:1659315398
Name:PHILLIPS, JENNIFER DAWN (RPA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RPA-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 488
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-0488
Mailing Address - Country:US
Mailing Address - Phone:866-853-9551
Mailing Address - Fax:203-916-1041
Practice Address - Street 1:240 REDTAIL DR
Practice Address - Street 2:STE 5&6
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-0000
Practice Address - Country:US
Practice Address - Phone:716-677-0454
Practice Address - Fax:716-712-0061
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347079Medicaid
NY95-11822OtherINDEPENDENT HEALTH
NY00026509002OtherUNIVERA
NY000570265003OtherBC/BS
NY02347079Medicaid
NY95-11822OtherINDEPENDENT HEALTH