Provider Demographics
NPI:1861473217
Name:IDE, DANA RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:RICHARD
Last Name:IDE
Suffix:
Gender:M
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:PO BOX 1754
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-1754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:STE 110
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-435-1003
Practice Address - Fax:610-435-3184
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002895L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1958641OtherHIGHMARK BLUE SHIELD
50053198OtherCAPITAL BLUE CROSS
50053198OtherKEYSTONE HEALTH CENTRAL
405198OtherHEALTHAMERICA/HEALTHASSUR
P00261573OtherRAILROAD MEDICARE
50053198OtherCAPITAL BLUE CROSS
PA095908Medicare PIN