Basic Information
| Provider Information | |||||||||
| NPI: | 1457653404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELLAGUARDIA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 826 MAIN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194604459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104151100 | ||||||||
| FaxNumber: | 6104151101 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 MAIN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194604459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104151100 | ||||||||
| FaxNumber: | 6104151101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2010 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA001519L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 177908 | 01 | PA | PTAN | OTHER | MA001519L | 01 | PA | LICENSE | OTHER |