Healthcare Provider Details

I. General information

NPI: 1538615380
Provider Name (Legal Business Name): PETERJASON LIGI RDN, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 5TH ST
MAYFIELD PA
18433
US

IV. Provider business mailing address

122 5TH ST
MAYFIELD PA
18433-1510
US

V. Phone/Fax

Practice location:
  • Phone: 570-267-6617
  • Fax:
Mailing address:
  • Phone: 570-267-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN005776
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: