Provider Demographics
NPI:1518996628
Name:FITTIPALDI, JESSICA MARIE (PAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:FITTIPALDI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:WANCHALK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2106 HARRISBURG PIKE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-393-1900
Mailing Address - Fax:888-972-8301
Practice Address - Street 1:2106 HARRISBURG PIKE
Practice Address - Street 2:SUITE 116
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-393-1900
Practice Address - Fax:888-972-8301
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052551363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q70304Medicare UPIN
102145RKKMedicare PIN