Healthcare Provider Details

I. General information

NPI: 1477647899
Provider Name (Legal Business Name): MICHAEL JOHN FEDOR CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SCHOOLHOUSE RD
MIDDLETOWN PA
17057-3548
US

IV. Provider business mailing address

PO BOX 858 MC A410
HERSHEY PA
17033-0858
US

V. Phone/Fax

Practice location:
  • Phone: 717-948-5180
  • Fax: 717-948-0488
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP009349
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00086500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: