Provider Demographics
NPI:1558426452
Name:FETSKO, RONALD P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:P
Last Name:FETSKO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:4186 CORTLAND DR
Practice Address - Street 2:BOX 367
Practice Address - City:NEW PARIS
Practice Address - State:PA
Practice Address - Zip Code:15554-7706
Practice Address - Country:US
Practice Address - Phone:814-839-4108
Practice Address - Fax:814-839-4845
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000268L207Q00000X
PAOA002202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S64371Medicare UPIN
PA170899Medicare PIN