Healthcare Provider Details

I. General information

NPI: 1295795656
Provider Name (Legal Business Name): GARY A PACYNA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 DRINKER TPKE STE 21
COVINGTON TOWNSHIP PA
18444-7948
US

IV. Provider business mailing address

921 DRINKER TPKE STE 21
COVINGTON TOWNSHIP PA
18444-7948
US

V. Phone/Fax

Practice location:
  • Phone: 570-842-0400
  • Fax: 570-842-1449
Mailing address:
  • Phone: 570-842-0400
  • Fax: 570-842-1449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0649380001
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC003408L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberSC003408L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberSC003408L
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberSC003408L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: