Provider Demographics
NPI:1508380742
Name:ROOT, ABIGAIL BACON (PA-C)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:BACON
Last Name:ROOT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:FRITZ
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:201 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16550-0002
Mailing Address - Country:US
Mailing Address - Phone:814-877-6139
Mailing Address - Fax:814-877-6093
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-6139
Practice Address - Fax:814-877-6093
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant