Healthcare Provider Details

I. General information

NPI: 1548594864
Provider Name (Legal Business Name): PHILIP EDWARD SEKUNDA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MOUNTAIN BLVD
WILKES BARRE PA
18711-0027
US

IV. Provider business mailing address

1000 E MOUNTAIN BLVD
WILKES BARRE PA
18711-0027
US

V. Phone/Fax

Practice location:
  • Phone: 570-808-5770
  • Fax:
Mailing address:
  • Phone: 570-808-5770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053998
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: