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General NPI Number Information
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NPI Number | 1487885091
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Entity Type | Individual
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Provider Name | ELAINE MARGUERITE DIMICCO PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 2 MI NORTH OF WHITEDEER
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City | WHITEDEER
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State | PA
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Zip | 17717
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Country | US
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Telephone | 570-547-0963
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Fax |
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Provider Business Mailing Address
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Address Line | 2 LIBERTY ST
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City | WATSONTOWN
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State | PA
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Zip | 17777-1315
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Country | US
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Telephone | 908-303-3566
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | MA054675
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License Number State | PA
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