Provider Demographics
NPI:1457653404
Name:DELLAGUARDIA, JENNIFER (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DELLAGUARDIA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4459
Mailing Address - Country:US
Mailing Address - Phone:610-415-1100
Mailing Address - Fax:610-415-1101
Practice Address - Street 1:826 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-4459
Practice Address - Country:US
Practice Address - Phone:610-415-1100
Practice Address - Fax:610-415-1101
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001519L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA177908OtherPTAN
PAMA001519LOtherLICENSE
PAMA001519LOtherLICENSE
PA786895GGMMedicare PIN
PAS04924Medicare UPIN