Provider Demographics
NPI:1205232709
Name:IVESON, WILLIAM DAVID (FNP-BC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:IVESON
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:SUSQUEHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18847-1511
Mailing Address - Country:US
Mailing Address - Phone:607-221-1318
Mailing Address - Fax:570-853-3008
Practice Address - Street 1:271 GRAND ST
Practice Address - Street 2:
Practice Address - City:SUSQUEHANNA
Practice Address - State:PA
Practice Address - Zip Code:18847-1511
Practice Address - Country:US
Practice Address - Phone:607-221-1318
Practice Address - Fax:570-853-3008
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014480363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily