Healthcare Provider Details

I. General information

NPI: 1952368342
Provider Name (Legal Business Name): JODY LIN MRAKOVICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODY LIN TRUESDALE

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SPRING GARDEN DR
MIDDLETOWN PA
17057-3257
US

IV. Provider business mailing address

1100 SPRING GARDEN DR STE 3
MIDDLETOWN PA
17057-3257
US

V. Phone/Fax

Practice location:
  • Phone: 717-985-9091
  • Fax: 717-985-6909
Mailing address:
  • Phone: 717-985-9091
  • Fax: 717-985-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA001689L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA000187L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA001689L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: