Provider Demographics
NPI:1013415264
Name:RESTIVO, JAMIE NICHOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICHOLE
Last Name:RESTIVO
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 1:1822 GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-1233
Mailing Address - Country:US
Mailing Address - Phone:717-763-7685
Mailing Address - Fax:
Practice Address - Street 1:1822 GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1233
Practice Address - Country:US
Practice Address - Phone:717-763-7685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCO6715363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant