Basic Information
| Provider Information | |||||||||
| NPI: | 1578072021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETWILER | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | FOSTER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 E WYNNEWOOD RD APT 10A | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190961526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536788998 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2722 CONCORD PIKE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024771406 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2017 | ||||||||
| LastUpdateDate: | 09/28/2017 | ||||||||
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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 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.