Provider Demographics
NPI:1427112317
Name:JENNINGS, MOSE ALPHONSO (PA)
Entity type:Individual
Prefix:MR
First Name:MOSE
Middle Name:ALPHONSO
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 SEAGULL DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-7408
Mailing Address - Country:US
Mailing Address - Phone:510-233-0058
Mailing Address - Fax:
Practice Address - Street 1:2425 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3358
Practice Address - Country:US
Practice Address - Phone:415-833-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 12212363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical