Healthcare Provider Details

I. General information

NPI: 1023440450
Provider Name (Legal Business Name): RALPH A. ODIERNO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 FRANKLIN AVE
PALMERTON PA
18071-1521
US

IV. Provider business mailing address

217 FRANKLIN AVE
PALMERTON PA
18071-1521
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-1735
  • Fax:
Mailing address:
  • Phone: 484-526-3990
  • Fax: 610-868-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA004381
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: