Provider Demographics
NPI:1750432027
Name:RADZIEWICZ, ELLEN E (PA-C)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:E
Last Name:RADZIEWICZ
Suffix:
Gender:F
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 1:210 MARJORAM DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-6014
Mailing Address - Country:US
Mailing Address - Phone:302-838-7228
Mailing Address - Fax:302-623-4064
Practice Address - Street 1:774 CHRISTIANA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4236
Practice Address - Country:US
Practice Address - Phone:302-623-4004
Practice Address - Fax:302-623-4064
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000359363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q02419Medicare UPIN
012881A59Medicare ID - Type Unspecified