Provider Demographics
NPI:1376972653
Name:MODESTO, CHELSEA
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:MODESTO
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 1:1901 HAMILTON ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-6459
Mailing Address - Country:US
Mailing Address - Phone:610-628-7920
Mailing Address - Fax:610-821-2853
Practice Address - Street 1:1901 HAMILTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6459
Practice Address - Country:US
Practice Address - Phone:610-628-7920
Practice Address - Fax:610-821-2853
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056423363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical