Provider Demographics
NPI:1801142526
Name:BAUER DE MUENZBERG, ELIZABETH M (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BAUER DE MUENZBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VALLEY VIEW
Practice Address - State:PA
Practice Address - Zip Code:17983-9423
Practice Address - Country:US
Practice Address - Phone:570-682-8026
Practice Address - Fax:570-682-8043
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002898363A00000X
PAMA055654363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA247049F6KOtherMEDICARE PTAN