Provider Demographics
NPI:1932487923
Name:BRUTUS, JENNIFER (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BRUTUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NICOLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1455 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2028
Mailing Address - Country:US
Mailing Address - Phone:516-314-3279
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0092221363AM0700X
NY009222-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical