Provider Demographics
NPI:1093257867
Name:SWANK, AUDREY M (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:SWANK
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 1:550 TRUMBULL AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9403
Mailing Address - Country:US
Mailing Address - Phone:330-637-2000
Mailing Address - Fax:330-637-2001
Practice Address - Street 1:550 TRUMBULL AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9403
Practice Address - Country:US
Practice Address - Phone:330-637-2000
Practice Address - Fax:330-637-2001
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004824RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGOtherANTHEM BCBS
OHPENDINGMedicaid