Provider Demographics
NPI:1043313083
Name:AVADANIAN, PAUL G (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:AVADANIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 A&B LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522
Mailing Address - Country:US
Mailing Address - Phone:717-721-7718
Mailing Address - Fax:717-721-7726
Practice Address - Street 1:136 A&B LAKE STREET
Practice Address - Street 2:LAKE STREET FAMILY PRACTICE
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522
Practice Address - Country:US
Practice Address - Phone:717-721-7718
Practice Address - Fax:717-721-7726
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008957L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA858854OtherBLUE SHIELD
PA0015922740004Medicaid
PA500048OtherAETNA
PA50051223OtherCAPITAL BLUE
PAP00255543OtherRAILROAD MEDICARE
PA500488OtherUSH/HMO
PAP002390OtherGATEWAY
PAP002390OtherGATEWAY
PA0015922740004Medicaid