Provider Demographics
NPI:1427042092
Name:BLACK, DAVID L (PAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:1700 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7529
Mailing Address - Country:US
Mailing Address - Phone:717-272-6621
Mailing Address - Fax:717-228-6156
Practice Address - Street 1:4310 LONDONDERRY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5300
Practice Address - Country:US
Practice Address - Phone:717-920-7664
Practice Address - Fax:717-920-4361
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA000813L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0993475OtherKEYSTONE
PA50041402OtherBLUE CROSS
PA0993475OtherKEYSTONE