Healthcare Provider Details

I. General information

NPI: 1144058462
Provider Name (Legal Business Name): MARIA ISABELLA DITHOMAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE STREET 1 PINE WEST
PHILADELPHIA PA
19107
US

IV. Provider business mailing address

410 SHURS LN APT 203B
PHILADELPHIA PA
19128-3553
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-7817
  • Fax:
Mailing address:
  • Phone: 412-728-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA065718
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: