Provider Demographics
NPI:1669728184
Name:FAULCONBRIDGE, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FAULCONBRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N BROAD STREET EXT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4603
Mailing Address - Country:US
Mailing Address - Phone:724-450-7246
Mailing Address - Fax:724-450-7247
Practice Address - Street 1:631 N BROAD STREET EXT
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4603
Practice Address - Country:US
Practice Address - Phone:724-450-7246
Practice Address - Fax:724-450-7247
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055505363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA246241Medicare PIN