Provider Demographics
NPI:1326201732
Name:RALSTON, DALE T (PA)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:T
Last Name:RALSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 199
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-0199
Mailing Address - Country:US
Mailing Address - Phone:610-521-6063
Mailing Address - Fax:610-521-0163
Practice Address - Street 1:1510 CHESTER PIKE
Practice Address - Street 2:SUITE 130
Practice Address - City:EDDYSTONE
Practice Address - State:PA
Practice Address - Zip Code:19022-1375
Practice Address - Country:US
Practice Address - Phone:610-521-6063
Practice Address - Fax:610-521-0163
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000732363AM0700X
PAMA000158L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA390026Medicare PIN