Provider Demographics
NPI:1184748212
Name:BAYNOSA, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:BAYNOSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:DELA PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 516558
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0596
Mailing Address - Country:US
Mailing Address - Phone:702-671-2391
Mailing Address - Fax:702-895-4014
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:#160
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-5150
Practice Address - Fax:702-384-6493
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12653208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1184748212Medicaid
NVV51698OtherPTAN