Provider Demographics
NPI:1942517412
Name:MEDOVIC, TY (PA-C)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:MEDOVIC
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 WASHINGTON RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-2765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 WASHINGTON RD
Practice Address - Street 2:SUITE 7
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-2765
Practice Address - Country:US
Practice Address - Phone:724-225-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054473363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical