Healthcare Provider Details

I. General information

NPI: 1487630224
Provider Name (Legal Business Name): ANDREA MARIE GOSHEN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA MARIE SCHANTZ PAC

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 NAZARETH RD STE 201
EASTON PA
18045-8338
US

IV. Provider business mailing address

PO BOX 20907
LEHIGH VALLEY PA
18002-0907
US

V. Phone/Fax

Practice location:
  • Phone: 610-923-9663
  • Fax: 610-923-9661
Mailing address:
  • Phone: 610-923-9663
  • Fax: 610-923-9661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTMA051526
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: