Provider Demographics
NPI:1326008970
Name:MARDULA, LINDA DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:DIANE
Last Name:MARDULA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:ATTN: SANDY ODGERS
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8344
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:236 JAMESWAY RD
Practice Address - Street 2:
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931-4207
Practice Address - Country:US
Practice Address - Phone:814-410-8344
Practice Address - Fax:814-410-8331
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2015-10-21
Deactivation Date:2015-06-17
Deactivation Code:
Reactivation Date:2015-10-21
Provider Licenses
StateLicense IDTaxonomies
PAMA002078L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00259042OtherRAILROAD MEDICARE
PA095681TB8Medicare ID - Type Unspecified
PAP00259042OtherRAILROAD MEDICARE