Provider Demographics
NPI:1891780854
Name:ERDESKY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ERDESKY
Suffix:
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 1:1708 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-8848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-2868
Practice Address - Country:US
Practice Address - Phone:724-983-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP60051Medicare UPIN
PA071869Medicare ID - Type Unspecified