Provider Demographics
NPI:1225262215
Name:IACOVONI, THOMAS JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:IACOVONI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:603 E MARKET ST
Mailing Address - Street 2:SUITE 200 - CMSU
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-2161
Mailing Address - Country:US
Mailing Address - Phone:570-275-4962
Mailing Address - Fax:570-275-3098
Practice Address - Street 1:603 E MARKET ST
Practice Address - Street 2:SUITE 200 - CMSU
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-2161
Practice Address - Country:US
Practice Address - Phone:570-275-4962
Practice Address - Fax:570-275-3098
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA053730363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical