Basic Information
| Provider Information | |||||||||
| NPI: | 1881873834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOATWRIGHT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RENEE MASTER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REECE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | RENEE MASTER | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135284975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 27343 WESLEY CHAPEL BLVD | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335444287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139919355 | ||||||||
| FaxNumber: | 8133555031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107775 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA9107775 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 014578600 | 05 | FL | MEDICAID | P01483687 | 01 | RR MEDICARE | OTHER |