Provider Demographics
NPI:1770551475
Name:DWYER, JENNIFER DEAN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DEAN
Last Name:DWYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21555 FIRESIDE CT
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-8704
Mailing Address - Country:US
Mailing Address - Phone:320-685-7091
Mailing Address - Fax:
Practice Address - Street 1:200 W 1ST ST
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1445
Practice Address - Country:US
Practice Address - Phone:320-243-3779
Practice Address - Fax:320-243-6707
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR04568Medicare UPIN