Provider Demographics
NPI:1619174380
Name:DAVIS MAZENKO, CHRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:DAVIS MAZENKO
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:PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-0907
Mailing Address - Country:US
Mailing Address - Phone:215-453-4995
Mailing Address - Fax:215-453-4646
Practice Address - Street 1:817 LAWN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1579
Practice Address - Country:US
Practice Address - Phone:215-257-8391
Practice Address - Fax:215-453-6955
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052671363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232612157OtherGROUP TAX ID