Provider Demographics
NPI:1578072021
Name:DETWILER, JOHANNA FOSTER (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:FOSTER
Last Name:DETWILER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E WYNNEWOOD RD APT 10A
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-1526
Mailing Address - Country:US
Mailing Address - Phone:253-678-8998
Mailing Address - Fax:
Practice Address - Street 1:2722 CONCORD PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-5007
Practice Address - Country:US
Practice Address - Phone:302-477-1406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical