Provider Demographics
NPI:1720167034
Name:ISIDRO, ALICE MAY (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:MAY
Last Name:ISIDRO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MAY
Other - Last Name:BERNABE ISIDRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:JD LANKENAU PAVILLION, MEZZANINE
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-476-1000
Mailing Address - Fax:484-476-9000
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:JD LANKENAU PAVILLION, MEZZANINE
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-1000
Practice Address - Fax:484-476-9000
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002647L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00616Medicare UPIN
PA110877Medicare PIN