Basic Information
Provider Information | |||||||||
NPI: | 1245877679 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CANDIOTTI | ||||||||
FirstName: | JORGE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CANDIOTTI HERRERA | ||||||||
OtherFirstName: | JORGE | ||||||||
OtherMiddleName: | LUIS | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 602 LEIGHTON CT | ||||||||
Address2: |   | ||||||||
City: | MARS | ||||||||
State: | PA | ||||||||
PostalCode: | 160467108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4128410723 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12311 PERRY HWY | ||||||||
Address2: |   | ||||||||
City: | WEXFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 150908344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8783324159 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2019 | ||||||||
LastUpdateDate: | 10/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA061288 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.