Healthcare Provider Details

I. General information

NPI: 1619227063
Provider Name (Legal Business Name): ALISA BENEDICT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 NATIONAL PIKE
HOPWOOD PA
15445-2250
US

IV. Provider business mailing address

105 CORNERSTONE CT
VENETIA PA
15367-2325
US

V. Phone/Fax

Practice location:
  • Phone: 724-437-2147
  • Fax:
Mailing address:
  • Phone: 724-777-1729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA055656
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: