Provider Demographics
NPI:1699204586
Name:CANTALOPE, DEVON
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:CANTALOPE
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 1:200 POST OFFICE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT BENEDICT
Mailing Address - State:PA
Mailing Address - Zip Code:15773-7703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2350
Practice Address - Country:US
Practice Address - Phone:814-643-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059088363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical