Provider Demographics
NPI:1790100527
Name:MISITI, GARY A JR
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:MISITI
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 SOUTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-4510
Mailing Address - Country:US
Mailing Address - Phone:717-741-1414
Mailing Address - Fax:717-741-4774
Practice Address - Street 1:2690 SOUTHFIELD DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4510
Practice Address - Country:US
Practice Address - Phone:717-741-1414
Practice Address - Fax:717-741-4774
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056736363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
342633G7JMedicare PIN