MEDICARE: MRS. DEBRA ANN BERTSCHE PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA002312L	PA
2	363AM0700X	Medical Physician Assistant	0057681	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0057681	OTHER	NY	NY LICENSE
2	MA002312L	OTHER	PA	STATE LICENSE

General Provider Information

NPI Number	:	1336220383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBRA ANN BERTSCHE PAC

Provider Business Mailing Address
First Line	:	601 PARK ST
Second Line	:
City	:	HONESDALE
State	:	PA
Zip	:	18431-1445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	273 GRANDVIEW AVE
Second Line	:
City	:	HONESDALE
State	:	PA
Zip	:	18431-1163
Country	:	US
Telephone Number	:	570-390-4545
Fax Number	:	570-390-4546

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	10/11/2023

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