Healthcare Provider Details

I. General information

NPI: 1639896798
Provider Name (Legal Business Name): ANGELO JOSEPH MARINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

301 WASHINGTON WOODS DR
WASHINGTON PA
15301-9584
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1000
  • Fax:
Mailing address:
  • Phone: 724-678-0327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: