Provider Demographics
NPI:1467559682
Name:RISKO, GARY F (PAC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:F
Last Name:RISKO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SOUTHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4330
Mailing Address - Country:US
Mailing Address - Phone:814-536-7045
Mailing Address - Fax:814-539-3927
Practice Address - Street 1:350 SOUTHMONT BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4330
Practice Address - Country:US
Practice Address - Phone:814-536-7045
Practice Address - Fax:814-539-3927
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002056L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA063932Medicare PIN
PAS44858Medicare UPIN