Basic Information
| Provider Information | |||||||||
| NPI: | 1659315398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 488 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142400488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668539551 | ||||||||
| FaxNumber: | 2039161041 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 REDTAIL DR | ||||||||
| Address2: | STE 5&6 | ||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141270000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166770454 | ||||||||
| FaxNumber: | 7167120061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 007111 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02347079 | 05 | NY | MEDICAID | 95-11822 | 01 | NY | INDEPENDENT HEALTH | OTHER | 00026509002 | 01 | NY | UNIVERA | OTHER | 000570265003 | 01 | NY | BC/BS | OTHER |