Provider Demographics
NPI:1558463117
Name:MASCIOTRA, NICHOLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:MASCIOTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MAIN ST
Mailing Address - Street 2:SUITE 4C
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901-1632
Mailing Address - Country:US
Mailing Address - Phone:814-536-7725
Mailing Address - Fax:814-539-3130
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:SUITE 4C
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1632
Practice Address - Country:US
Practice Address - Phone:814-536-7725
Practice Address - Fax:814-539-3130
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25-1562722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA072559OtherHIGHMARK
PA0007090690001Medicaid
PA072559OtherHIGHMARK
PAB34983Medicare UPIN