Basic Information
| Provider Information | |||||||||
| NPI: | 1245583665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEPANFILIS | ||||||||
| FirstName: | JACKI | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVISON | ||||||||
| OtherFirstName: | JACKI | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 METOXET ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | RIDGWAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158531932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147728122 | ||||||||
| FaxNumber: | 8147727278 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 METOXET ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | RIDGWAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158531932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147728122 | ||||||||
| FaxNumber: | 8147727278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2012 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA055834 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.