Provider Demographics
NPI:1043316870
Name:DESTEFANO, THOMAS J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:DESTEFANO
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:429 INDUSTRIAL PARK DR
Mailing Address - Street 2:PBG HEALTH AND WELLNESS CENTER
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-262-1219
Mailing Address - Fax:814-262-1259
Practice Address - Street 1:429 INDUSTRIAL PARK DR
Practice Address - Street 2:PBG HEALTH AND WELLNESS CENTER
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-262-1219
Practice Address - Fax:814-262-1259
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2008-08-25
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Provider Licenses
StateLicense IDTaxonomies
PAMA002812L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA096979MK6Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER