Provider Demographics
NPI:1003143330
Name:EDELBLUTE, ALICIA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:RENEE
Last Name:EDELBLUTE
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 1:4299 RIDERS LN
Mailing Address - Street 2:
Mailing Address - City:UPPER CHICHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19061-2644
Mailing Address - Country:US
Mailing Address - Phone:610-406-7662
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:610-406-7662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDE C5 0000687363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEDE C50000687OtherDE STATE BOARD OF MEDICINE