Basic Information
| Provider Information | |||||||||
| NPI: | 1184748212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAYNOSA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELA PENA | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 516558 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026712391 | ||||||||
| FaxNumber: | 7028954014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 W CHARLESTON BLVD | ||||||||
| Address2: | #160 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026715150 | ||||||||
| FaxNumber: | 7023846493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 12653 | NV | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | 12653 | NV | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1184748212 | 05 | NV | MEDICAID | V51698 | 01 | NV | PTAN | OTHER |