MEDICARE: MS. JODI LEE CONDRON PA-C

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	363AS0400X	Surgical Physician Assistant	MA002755L	PA

General Provider Information

NPI Number	:	1346240017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JODI LEE CONDRON PA-C

Provider Business Mailing Address
First Line	:	301 E 1ST AVE
Second Line	:
City	:	TARENTUM
State	:	PA
Zip	:	15084-1858
Country	:	US
Telephone Number	:	412-826-1065
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 E 1ST AVE
Second Line	:
City	:	TARENTUM
State	:	PA
Zip	:	15084-1858
Country	:	US
Telephone Number	:	412-826-1065
Fax Number	:

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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