Provider Demographics
NPI:1689220782
Name:PENNACHIO, ALEX JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JAMES
Last Name:PENNACHIO
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 1:175 E BROWN ST STE 201A
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3098
Mailing Address - Country:US
Mailing Address - Phone:570-395-2500
Mailing Address - Fax:
Practice Address - Street 1:175 E BROWN ST STE 201A
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3098
Practice Address - Country:US
Practice Address - Phone:570-395-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060743363A00000X
PAOA004890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant