Healthcare Provider Details

I. General information

NPI: 1841286317
Provider Name (Legal Business Name): DONNA M MORTIMER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BUSTLETON PIKE STE 100
FEASTERVILLE TREVOSE PA
19053-6446
US

IV. Provider business mailing address

12265 TOWNSEND RD
PHILADELPHIA PA
19154-1201
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-9599
  • Fax: 215-464-7865
Mailing address:
  • Phone: 215-856-1010
  • Fax: 215-856-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA051640
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: