Provider Demographics
NPI:1770608481
Name:MACNEELY, PAMELA LEA (PA-C)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:LEA
Last Name:MACNEELY
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 1:675 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3831
Mailing Address - Country:US
Mailing Address - Phone:570-288-4205
Mailing Address - Fax:
Practice Address - Street 1:675 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3831
Practice Address - Country:US
Practice Address - Phone:570-288-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002498L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071202Medicare ID - Type Unspecified
PA071202Medicare UPIN