Provider Demographics
NPI:1811589518
Name:HUA, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HUA
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 1:2273 E GALA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7289
Mailing Address - Country:US
Mailing Address - Phone:208-273-1573
Mailing Address - Fax:
Practice Address - Street 1:2273 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-273-1573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2081363A00000X
PAOA005631363A00000X
PAMA062503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1S2685OtherMEDICARE
PA1039169190001Medicaid