Basic Information
| Provider Information | |||||||||
| NPI: | 1598113870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYOMING VALLEY PATHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1205 | ||||||||
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| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702085525 | ||||||||
| FaxNumber: | 5702085556 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LAIRD ST | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187027020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708298111 | ||||||||
| FaxNumber: | 5702085556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2016 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | AHMAD | ||||||||
| AuthorizedOfficialFirstName: | NAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5705521435 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 39D2118978 | 01 | PA | CLIA | OTHER |