Provider Demographics
NPI:1487885091
Name:DIMICCO, ELAINE MARGUERITE (PA-C)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARGUERITE
Last Name:DIMICCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WATSONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17777-1315
Mailing Address - Country:US
Mailing Address - Phone:908-303-3566
Mailing Address - Fax:
Practice Address - Street 1:2 MI NORTH OF WHITEDEER
Practice Address - Street 2:
Practice Address - City:WHITEDEER
Practice Address - State:PA
Practice Address - Zip Code:17717
Practice Address - Country:US
Practice Address - Phone:570-547-0963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant