Provider Demographics
NPI:1336709732
Name:PICKERAL, CAITLIN T (PA)
Entity Type:Individual
Prefix:MS
First Name:CAITLIN
Middle Name:T
Last Name:PICKERAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:THOMAS
Other - Last Name:PICKERAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2777
Mailing Address - Fax:215-662-4613
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2777
Practice Address - Fax:215-662-4613
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062410363A00000X
VA0110006881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant