Healthcare Provider Details

I. General information

NPI: 1831253467
Provider Name (Legal Business Name): PEQUEA VALLEY INTERNAL MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 OREGON PIKE SUITE 107 B
LANCASTER PA
17601-4206
US

IV. Provider business mailing address

1725 OREGON PIKE SUITE 107 B
LANCASTER PA
17601-4206
US

V. Phone/Fax

Practice location:
  • Phone: 717-560-3505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. JESSICA R LACORTE
Title or Position: PRACTICE ADMINISTRATOR
Credential: RN
Phone: 717-560-3505