Provider Demographics
NPI:1407845845
Name:WITCOSKI, JEREMY D (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:WITCOSKI
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 1:250 CETRONIA RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-9147
Mailing Address - Country:US
Mailing Address - Phone:610-973-6200
Mailing Address - Fax:866-644-0894
Practice Address - Street 1:250 CETRONIA RD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9147
Practice Address - Country:US
Practice Address - Phone:610-973-6200
Practice Address - Fax:866-644-0894
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103071363A00000X
PAMA056681363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3984ZMedicare ID - Type Unspecified
FLQ31660Medicare UPIN
FLK2434Medicare ID - Type Unspecified