MEDICARE: MRS. LISA M MATTEI 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	363A00000X	Physician Assistant	OA000886	PA
2	363A00000X	Physician Assistant	AO000886	PA

General Provider Information

NPI Number	:	1902889629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA M MATTEI PAC

Provider Business Mailing Address
First Line	:	100 N ACADEMY AVE
Second Line	:
City	:	DANVILLE
State	:	PA
Zip	:	17822-4903
Country	:	US
Telephone Number	:	570-271-6144
Fax Number	:	570-271-6578

Provider Business Practice Location Address
First Line	:	1155 E MOUNTAIN BLVD
Second Line	:
City	:	WILKES BARRE
State	:	PA
Zip	:	18702-7906
Country	:	US
Telephone Number	:	570-808-5135
Fax Number	:	570-808-5136

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	11/11/2020

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