Provider Demographics
NPI:1760986939
Name:WADA, JENNY JOHANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:JOHANNA
Last Name:WADA
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 1:311 E 76TH ST APT 17
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2430
Mailing Address - Country:US
Mailing Address - Phone:347-400-7369
Mailing Address - Fax:
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant