Provider Demographics
NPI:1407845845
Name:WITCOSKI, JEREMY D (PA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:WITCOSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-526-1735
Mailing Address - Fax:866-230-6583
Practice Address - Street 1:501 CETRONIA RD STE 125
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9569
Practice Address - Country:US
Practice Address - Phone:484-526-1735
Practice Address - Fax:866-230-6583
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056681363A00000X
FLPA9103071363A00000X
NJ25MP00486300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3984ZMedicare ID - Type Unspecified
FLQ31660Medicare UPIN
FLK2434Medicare ID - Type Unspecified