Provider Demographics
NPI:1790774297
Name:PEDRAZA, JAIME (PA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:PEDRAZA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3902
Mailing Address - Country:US
Mailing Address - Phone:610-619-7360
Mailing Address - Fax:610-619-7366
Practice Address - Street 1:30 MEDICAL CENTER BLVD BLDG 1
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-3955
Practice Address - Country:US
Practice Address - Phone:610-874-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2779363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA-002409-LOtherPENNSYLVANIA LICENCE
FLPA2779OtherMEDICAL LICENSE
FLPA2779OtherMEDICAL LICENSE