Provider Demographics
NPI:1689908980
Name:CHRISTENBURY, JENNIFER HASTER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HASTER
Last Name:CHRISTENBURY
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:STE 360
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1248
Practice Address - Country:US
Practice Address - Phone:704-304-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0863PAMedicaid
NC1689908980Medicaid
NCNCC482GMedicare PIN
NCNCC482BMedicare PIN
NCNCC482AMedicare PIN
NCNCC482CMedicare PIN
NCNCC4820386Medicare PIN
NC2762028Medicare PIN
NCNCC482DMedicare PIN
NCNCC482EMedicare PIN