Provider Demographics
NPI:1083162671
Name:DIMITRIADIS, ALEXANDROS (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDROS
Middle Name:
Last Name:DIMITRIADIS
Suffix:
Gender:M
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 1:255 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:PALMERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18071-1812
Mailing Address - Country:US
Mailing Address - Phone:610-826-4595
Mailing Address - Fax:
Practice Address - Street 1:255 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PALMERTON
Practice Address - State:PA
Practice Address - Zip Code:18071-1812
Practice Address - Country:US
Practice Address - Phone:610-826-4595
Practice Address - Fax:610-826-4399
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058485363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033791750001Medicaid