Provider Demographics
NPI:1316220452
Name:PAVESE, JOHN W (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:PAVESE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1623 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2031
Mailing Address - Country:US
Mailing Address - Phone:570-340-5079
Mailing Address - Fax:570-340-5896
Practice Address - Street 1:746 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1624
Practice Address - Country:US
Practice Address - Phone:570-340-5079
Practice Address - Fax:570-340-5896
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA055176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA229181Medicare PIN