=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710450291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGET LOLLI PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2019
-----------------------------------------------------
Last Update Date | 12/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 INDUSTRIAL BLVD STE 200
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19301-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-647-4161
-----------------------------------------------------
Fax | 610-647-5397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 176 S NEW MIDDLETOWN RD STE 203
-----------------------------------------------------
City | MEDIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19063-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-566-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | C5-0001279
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA0060492
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------