Provider Demographics
NPI:1245906619
Name:BROUTY, JENNIFER (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROUTY
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CANNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-9703
Mailing Address - Country:US
Mailing Address - Phone:315-519-5724
Mailing Address - Fax:
Practice Address - Street 1:22075 CONSTITUTION DRIVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619
Practice Address - Country:US
Practice Address - Phone:315-519-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY027038207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant