Provider Demographics
NPI:1518622455
Name:PEDULLA, ANTONIO JR (CRNP)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:PEDULLA
Suffix:JR
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 FREMONT RD
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19362-9142
Mailing Address - Country:US
Mailing Address - Phone:610-733-8627
Mailing Address - Fax:
Practice Address - Street 1:680 FREMONT RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:PA
Practice Address - Zip Code:19362-9142
Practice Address - Country:US
Practice Address - Phone:610-733-8627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN674446163W00000X
PASP024827363LF0000X
PASP027026363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily