Healthcare Provider Details

I. General information

NPI: 1285057026
Provider Name (Legal Business Name): ERIC A RUNQUIST PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NEWTOWN-LANGHORNE RD ST MARY MEDICAL CENTER OPERATING ROOM
LANGHORNE PA
19047-1306
US

IV. Provider business mailing address

695 US HIGHWAY 46 STE 400A
FAIRFIELD NJ
07004-1568
US

V. Phone/Fax

Practice location:
  • Phone: 215-710-2000
  • Fax:
Mailing address:
  • Phone: 973-826-8291
  • Fax: 888-972-6480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA001381L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: