Healthcare Provider Details

I. General information

NPI: 1962779447
Provider Name (Legal Business Name): MARGUERITE EVANOFF-JURKOVIC D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 PEACH ST SUITE 3500
ERIE PA
16509-2601
US

IV. Provider business mailing address

1 LECOM PL
ERIE PA
16505-2571
US

V. Phone/Fax

Practice location:
  • Phone: 814-868-2179
  • Fax: 814-868-2346
Mailing address:
  • Phone:
  • Fax: 814-868-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOS007988
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: