Provider Demographics
NPI:1679198535
Name:MACON, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 TAYLOR AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-5553
Mailing Address - Country:US
Mailing Address - Phone:724-575-5059
Mailing Address - Fax:412-593-5116
Practice Address - Street 1:221 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-5432
Practice Address - Country:US
Practice Address - Phone:724-575-5059
Practice Address - Fax:412-593-5116
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist