Provider Demographics
NPI:1497316996
Name:PRACTITIONER LLC
Entity Type:Organization
Organization Name:PRACTITIONER LLC
Other - Org Name:NP MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIMARY CARE PROVIDER, SHAREHOLDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NINO
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVTARADZE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:267-223-7738
Mailing Address - Street 1:1200 BUSTLETON PIKE STE 16A3
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4118
Mailing Address - Country:US
Mailing Address - Phone:267-223-7738
Mailing Address - Fax:
Practice Address - Street 1:1200 BUSTLETON PIKE STE 16A3
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4118
Practice Address - Country:US
Practice Address - Phone:267-223-7738
Practice Address - Fax:877-416-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1037033750001Medicaid