Provider Demographics
NPI:1417909391
Name:PHILLIPS, LINDA MARANOWSKI (PA-CERTIFIED)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:MARANOWSKI
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 STONYCREEK ST
Mailing Address - Street 2:
Mailing Address - City:BOSWELL
Mailing Address - State:PA
Mailing Address - Zip Code:15531-1024
Mailing Address - Country:US
Mailing Address - Phone:814-629-5612
Mailing Address - Fax:814-629-7199
Practice Address - Street 1:136 S PINE AVE
Practice Address - Street 2:BOX 340
Practice Address - City:STOYSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15563-6002
Practice Address - Country:US
Practice Address - Phone:814-893-5568
Practice Address - Fax:814-893-5989
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000081L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007698380002Medicaid
PA1007698380001Medicaid
PA069206Medicare PIN
PA393820Medicare PIN
PA1007698380001Medicaid
PA424029EWSMedicare PIN
PA1007698380002Medicaid