Provider Demographics
NPI:1710437348
Name:FAYETTE PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:FAYETTE PHYSICIAN NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-430-8035
Mailing Address - Street 1:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:PA
Mailing Address - Zip Code:15477-0524
Mailing Address - Country:US
Mailing Address - Phone:724-678-9772
Mailing Address - Fax:
Practice Address - Street 1:111 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:GRINDSTONE
Practice Address - State:PA
Practice Address - Zip Code:15442-1105
Practice Address - Country:US
Practice Address - Phone:724-785-2286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty