Healthcare Provider Details

I. General information

NPI: 1649793159
Provider Name (Legal Business Name): DOM N ACHARYA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S 17TH ST
HARRISBURG PA
17104-1123
US

IV. Provider business mailing address

110 S 17TH ST
HARRISBURG PA
17104-1123
US

V. Phone/Fax

Practice location:
  • Phone: 717-232-9971
  • Fax:
Mailing address:
  • Phone: 717-232-9971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA059150
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: