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General NPI Number Information
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NPI Number | 1962469486
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Entity Type | Organization
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Legal Business Name | PORT ALLEGANY AREA FAMILY PRACTICE PC
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Dates
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Enumeration Date | 04/27/2006
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Last Update Date | 06/22/2022
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Provider Practice Location Address
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Address Line | 1 WILLOW ST
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City | PORT ALLEGANY
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State | PA
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Zip | 16743-1332
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Country | US
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Telephone | 814-642-9531
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Fax | 814-642-2020
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Provider Business Mailing Address
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Address Line | 1 WILLOW ST
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City | PORT ALLEGANY
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State | PA
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Zip | 16743-1332
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Country | US
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Telephone | 814-642-9531
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Fax | 814-642-2020
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK H SHELLEY
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Credential | M.D.
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Telephone | 814-642-9531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD029656E
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | MA053689
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | SP008214
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | SP009929
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License Number State | PA
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Taxonomy #5
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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