MEDICARE: JONATHAN ADAM PELLECHIA 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	363AM0700X	Medical Physician Assistant	2005035361	MO

General Provider Information

NPI Number	:	1528198439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN ADAM PELLECHIA PA-C

Provider Business Mailing Address
First Line	:	11155 DUNN RD STE 315E
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6111
Country	:	US
Telephone Number	:	314-355-7500
Fax Number	:	314-355-3287

Provider Business Practice Location Address
First Line	:	11155 DUNN RD STE 315E
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6111
Country	:	US
Telephone Number	:	314-355-7500
Fax Number	:	314-355-3287

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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