Healthcare Provider Details

I. General information

NPI: 1518225895
Provider Name (Legal Business Name): CAITLAN LISA PYDEN KOAH PA-C, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAITLAN LISA PYDEN PA-C, MS

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W. LANCASTER AVE
PAOLI PA
19301
US

IV. Provider business mailing address

255 W. LANCASTER AVE
PAOLI PA
19301
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax: 484-565-1513
Mailing address:
  • Phone: 484-565-1510
  • Fax: 484-565-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA055429
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: