Healthcare Provider Details

I. General information

NPI: 1689661290
Provider Name (Legal Business Name): FAMILY PRACTICE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E CHURCH ST
LOCK HAVEN PA
17745
US

IV. Provider business mailing address

112 E CHURCH ST
LOCK HAVEN PA
17745-2008
US

V. Phone/Fax

Practice location:
  • Phone: 570-293-4933
  • Fax:
Mailing address:
  • Phone: 570-293-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIJAH HANNA
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 570-293-4933