Provider Demographics
NPI:1518964717
Name:PELLEGRINO, DARIA LATCH (PA-C)
Entity Type:Individual
Prefix:
First Name:DARIA
Middle Name:LATCH
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DARIA
Other - Middle Name:
Other - Last Name:LATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1401 S 31ST ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-3506
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:5501 WOODLAND AVENUE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19143
Practice Address - Country:UM
Practice Address - Phone:215-724-4700
Practice Address - Fax:215-724-3111
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000041L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA072937KQCMedicare ID - Type Unspecified
S71947Medicare UPIN