Healthcare Provider Details

I. General information

NPI: 1588643472
Provider Name (Legal Business Name): CHRISTY L FEDORWICH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 S 4TH ST
LEBANON PA
17042-6111
US

IV. Provider business mailing address

33 LEWIS RD 2ND FL
BINGHAMTON NY
13905
US

V. Phone/Fax

Practice location:
  • Phone: 717-270-3751
  • Fax:
Mailing address:
  • Phone: 607-770-0025
  • Fax: 607-729-3986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMP00218800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024817
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001613
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: