Provider Demographics
NPI:1578559670
Name:PAGANA-DEFAZIO, JESSICA BARBARA (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BARBARA
Last Name:PAGANA-DEFAZIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BARBARA
Other - Last Name:PAGANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1072 MARKET ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-2458
Practice Address - Country:US
Practice Address - Phone:570-286-8521
Practice Address - Fax:570-286-6197
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA745913OtherMEDICARE PTAN
PA0018921720001Medicaid
PA1375554OtherPA. BLUE SHIELD
PA0018921720001Medicaid
PA50015384OtherCAPITAL BLUE CROSS
PA0018921720001Medicaid