Provider Demographics
NPI:1619381597
Name:PINE, DUSTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:
Last Name:PINE
Suffix:
Gender:M
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 1:214 PEACH ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:MC CONNELLSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17233-8559
Mailing Address - Country:US
Mailing Address - Phone:717-485-6110
Mailing Address - Fax:717-485-6106
Practice Address - Street 1:214 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:MC CONNELLSBURG
Practice Address - State:PA
Practice Address - Zip Code:17233-8559
Practice Address - Country:US
Practice Address - Phone:717-485-6110
Practice Address - Fax:717-485-6106
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031563760001Medicaid
PA867633OtherMEDICARE GROUP # WITH SPS