Healthcare Provider Details

I. General information

NPI: 1508380742
Provider Name (Legal Business Name): ABIGAIL BACON ROOT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABIGAIL FRITZ BACON PA-C

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 STATE ST
ERIE PA
16550-0002
US

IV. Provider business mailing address

201 STATE ST
ERIE PA
16550-0002
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-6139
  • Fax: 814-877-6093
Mailing address:
  • Phone: 814-877-6139
  • Fax: 814-877-6093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA059181
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: