Provider Demographics
NPI:1700148459
Name:BELANCIO, PATRICIA WALLACE (CRNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:WALLACE
Last Name:BELANCIO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:DOLORES
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9010
Mailing Address - Fax:215-226-8285
Practice Address - Street 1:1722 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1644
Practice Address - Country:US
Practice Address - Phone:215-233-9700
Practice Address - Fax:215-233-9710
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011629363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100727800OtherMEDICAID TPI GROUP
PA597586OtherMEDICARE TPI GROUP
PACD4829OtherRAILROAD MEDICARE TPI GROUP