Healthcare Provider Details

I. General information

NPI: 1245877679
Provider Name (Legal Business Name): JORGE L CANDIOTTI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JORGE LUIS CANDIOTTI HERRERA

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 LANCASTER DR
GRAPEVINE TX
76051-3544
US

IV. Provider business mailing address

602 LEIGHTON CT
MARS PA
16046-7108
US

V. Phone/Fax

Practice location:
  • Phone: 855-893-5637
  • Fax:
Mailing address:
  • Phone: 412-841-0723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061288
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17258
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: