Provider Demographics
NPI:1619916111
Name:DECKARD, BETH GINGRICH (CRNP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:GINGRICH
Last Name:DECKARD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:E
Other - Last Name:GINGRICH
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 1:21 SUSQUEHANNA VALLEY MALL DR STE A
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9148
Practice Address - Country:US
Practice Address - Phone:570-374-7852
Practice Address - Fax:570-374-7932
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP005262B363L00000X
PARN266917L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031841380001Medicaid