Healthcare Provider Details

I. General information

NPI: 1710437348
Provider Name (Legal Business Name): FAYETTE PHYSICIAN NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ROBERTS RD
GRINDSTONE PA
15442-1105
US

IV. Provider business mailing address

PO BOX 524
ROSCOE PA
15477-0524
US

V. Phone/Fax

Practice location:
  • Phone: 724-785-2286
  • Fax:
Mailing address:
  • Phone: 724-678-9772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA058454
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DOROTHY KNIGHT
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 724-430-8035