MEDICARE: JACQUELINE RODERICK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA056205	PA

General Provider Information

NPI Number	:	1811320054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RODERICK PA-C

Provider Business Mailing Address
First Line	:	PO BOX 824301
Second Line	:	SUITE 1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19182-4031
Country	:	US
Telephone Number	:	610-459-3278
Fax Number	:	781-276-6411

Provider Business Practice Location Address
First Line	:	1572 WILMINGTON PIKE
Second Line	:	SUITE 1
City	:	WEST CHESTER
State	:	PA
Zip	:	19382-8371
Country	:	US
Telephone Number	:	610-459-3278
Fax Number	:	781-276-6411

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2013
Last Update Date	:	08/12/2013

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