Basic Information
| Provider Information | |||||||||
| NPI: | 1255511531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SNOW | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | FITTS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 74 PLEASANT ST | ||||||||
| Address2: | STE 204 | ||||||||
| City: | NEW LONDON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032575881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039260088 | ||||||||
| FaxNumber: | 6039262853 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033017539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032257000 | ||||||||
| FaxNumber: | 6032307218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0703 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | AP2435 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 30337120 | 05 | NH | MEDICAID |