Healthcare Provider Details

I. General information

NPI: 1215982210
Provider Name (Legal Business Name): MATTHEW DIRODIO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 HIGHLANDS DR
LITITZ PA
17543-7694
US

IV. Provider business mailing address

2001 HAMPTON CT
MORGANTOWN PA
19543-8852
US

V. Phone/Fax

Practice location:
  • Phone: 717-625-5000
  • Fax:
Mailing address:
  • Phone: 610-913-6603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA000969L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: