Basic Information
Provider Information | |||||||||
NPI: | 1740713635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCGOVERN | ||||||||
FirstName: | DANIELLE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PETERS | ||||||||
OtherFirstName: | DANIELLE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1201 GRAMPIAN BLVD | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 177011900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8886479600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 900 PLAZA DR | ||||||||
Address2: |   | ||||||||
City: | MONTOURSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 177542448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5703683321 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2017 | ||||||||
LastUpdateDate: | 08/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OT018193 | PA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | OS020286 | PA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.