Provider Demographics
NPI:1891078937
Name:POLTERSDORF, DANIELLE L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:L
Last Name:POLTERSDORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:LYNN
Other - Last Name:PACHKOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:755 NORMAN DR
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7497
Mailing Address - Country:US
Mailing Address - Phone:717-273-6706
Mailing Address - Fax:717-273-1435
Practice Address - Street 1:755 NORMAN DR
Practice Address - Street 2:CREDENTIALS DEPT
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7497
Practice Address - Country:US
Practice Address - Phone:717-273-6706
Practice Address - Fax:717-273-1435
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant