Provider Demographics
NPI:1750005096
Name:PRATOR, IAN GRIFFIN (PA-C)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:GRIFFIN
Last Name:PRATOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 PHEASANT RD
Mailing Address - Street 2:
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353-8033
Mailing Address - Country:US
Mailing Address - Phone:484-752-8170
Mailing Address - Fax:
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:866-785-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant