Healthcare Provider Details

I. General information

NPI: 1750393765
Provider Name (Legal Business Name): IVONA AGATA KOCON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E END BLVD
WILKES BARRE PA
18711-0030
US

IV. Provider business mailing address

5 WILDWOOD LN
MOUNTAIN TOP PA
18707-9663
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-3521
  • Fax:
Mailing address:
  • Phone: 570-868-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA002563L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: