Provider Demographics
NPI:1275816001
Name:GEORGE, DANETTE
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 RODGERS AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-1061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:792 GALLITZIN RD
Practice Address - Street 2:
Practice Address - City:CRESSON
Practice Address - State:PA
Practice Address - Zip Code:16630-2213
Practice Address - Country:US
Practice Address - Phone:814-886-8161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001438L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA001438LOtherSTATE LICENSE