Provider Demographics
NPI:1598731028
Name:TACCONI, KIMBERLY ANN (PAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:TACCONI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 INDEPENDENCE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SCHNECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078
Mailing Address - Country:US
Mailing Address - Phone:610-769-4200
Mailing Address - Fax:610-769-4204
Practice Address - Street 1:4110 INDEPENDENCE DR
Practice Address - Street 2:STE 300
Practice Address - City:SCHNECKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18078
Practice Address - Country:US
Practice Address - Phone:610-769-4200
Practice Address - Fax:610-769-4204
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002219L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S24356Medicare ID - Type Unspecified
S24356Medicare UPIN