Provider Demographics
NPI:1851401277
Name:PESEK, CAROL L (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:PESEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:L
Other - Last Name:ALTHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 HOYLAKE CT
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19311-9638
Mailing Address - Country:US
Mailing Address - Phone:610-880-6404
Mailing Address - Fax:
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 134
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-452-3000
Practice Address - Fax:302-452-3003
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051531363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075143Medicare ID - Type Unspecified
PAQ02720Medicare UPIN