Healthcare Provider Details

I. General information

NPI: 1750385720
Provider Name (Legal Business Name): JEAN MOUBARAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 03/25/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E 2ND ST FL 2 2ND FLOOR
ERIE PA
16507-1579
US

IV. Provider business mailing address

333 STATE ST STE 103 2ND FLOOR
ERIE PA
16507-1450
US

V. Phone/Fax

Practice location:
  • Phone: 814-456-8980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD067456-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: