Provider Demographics
NPI:1245877679
Name:CANDIOTTI, JORGE L (PA-C)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:CANDIOTTI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JORGE
Other - Middle Name:LUIS
Other - Last Name:CANDIOTTI HERRERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:602 LEIGHTON CT
Mailing Address - Street 2:
Mailing Address - City:MARS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-7108
Mailing Address - Country:US
Mailing Address - Phone:412-841-0723
Mailing Address - Fax:
Practice Address - Street 1:1604 LANCASTER DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3544
Practice Address - Country:US
Practice Address - Phone:855-893-5637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061288363A00000X
TXPA17258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant