Provider Demographics
NPI:1053328492
Name:TOMALAVAGE, KENNETH W (PAC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:TOMALAVAGE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3399 TRINDLE RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-4407
Mailing Address - Country:US
Mailing Address - Phone:717-761-5530
Mailing Address - Fax:717-737-7197
Practice Address - Street 1:3399 TRINDLE RD
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011
Practice Address - Country:US
Practice Address - Phone:717-761-5530
Practice Address - Fax:717-737-7197
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001178L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50026375OtherCAPITAL BC
PA160299Medicare PIN
PAP00013497Medicare PIN
PA50026375OtherCAPITAL BC
PA069523Medicare PIN