Healthcare Provider Details

I. General information

NPI: 1265986111
Provider Name (Legal Business Name): THOMAS FEDORKO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 CHERRINGTON PKWY SUITE 201
MOON TWP PA
15108-4318
US

IV. Provider business mailing address

725 CHERRINGTON PKWY
MOON TWP PA
15108-4318
US

V. Phone/Fax

Practice location:
  • Phone: 412-264-6192
  • Fax: 412-264-6196
Mailing address:
  • Phone: 412-264-6192
  • Fax: 412-264-6196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE1002873
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: