Basic Information
| Provider Information | |||||||||
| NPI: | 1790875698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 CONCOURSE BLVD | ||||||||
| Address2: | STE 190 | ||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230595759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390251 | ||||||||
| FaxNumber: | 7579349497 | ||||||||
| Practice Location | |||||||||
| Address1: | 10800 MIDLOTHIAN TPKE STE 309 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045494040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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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 | 363A00000X | 110002369 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00365127 | 01 | VA | RAILROAD MEDICARE | OTHER |