Provider Demographics
NPI:1265854509
Name:MOBILE MEDICAL PRACTITIONERS
Entity Type:Organization
Organization Name:MOBILE MEDICAL PRACTITIONERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-701-8153
Mailing Address - Street 1:111 PRESIDENTIAL BLVD STE 165
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1005
Mailing Address - Country:US
Mailing Address - Phone:215-701-8153
Mailing Address - Fax:
Practice Address - Street 1:111 PRESIDENTIAL BLVD STE 165
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1005
Practice Address - Country:US
Practice Address - Phone:215-701-8153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty