Provider Demographics
NPI:1326319443
Name:LOBRUTTO, PAUL TYLER (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:TYLER
Last Name:LOBRUTTO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 OLD FERN HILL RD
Mailing Address - Street 2:BLDG. A STE. 1
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4269
Mailing Address - Country:US
Mailing Address - Phone:610-692-6280
Mailing Address - Fax:
Practice Address - Street 1:915 OLD FERN HILL RD
Practice Address - Street 2:BLDG. A STE. 1
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4269
Practice Address - Country:US
Practice Address - Phone:610-692-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056893363A00000X
015407363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
358186NU9Medicare UPIN