Provider Demographics
NPI:1255388815
Name:LY, ALLISON D (PA-C)
Entity type:Individual
Prefix:MS
First Name:ALLISON
Middle Name:D
Last Name:LY
Suffix:
Gender:F
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 1:367 S. GULPH RD
Mailing Address - Street 2:ATTN: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:561-333-4000
Mailing Address - Fax:
Practice Address - Street 1:3319 S STATE ROAD 7 STE 102
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8099
Practice Address - Country:US
Practice Address - Phone:561-333-4000
Practice Address - Fax:561-333-8851
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100938363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291006300Medicaid
FL291006300Medicaid
FLE2853Medicare ID - Type Unspecified