Healthcare Provider Details

I. General information

NPI: 1538514492
Provider Name (Legal Business Name): MYPAFOOTDOCTOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/30/2023
Certification Date: 04/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 BALTIMORE ST STE 1
HANOVER PA
17331-4400
US

IV. Provider business mailing address

1055 BALTIMORE ST STE 1
HANOVER PA
17331-4400
US

V. Phone/Fax

Practice location:
  • Phone: 717-524-1034
  • Fax: 833-524-1034
Mailing address:
  • Phone: 717-524-1034
  • Fax: 833-524-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC006213
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JIM MAXKA
Title or Position: SOLE OWNER
Credential: DPM
Phone: 717-524-1034