Provider Demographics
NPI:1841472859
Name:OB-GYN OF LANCASTER, INC ADV NURSING PROV
Entity type:Organization
Organization Name:OB-GYN OF LANCASTER, INC ADV NURSING PROV
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:STRECK
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, CAC
Authorized Official - Phone:717-390-2589
Mailing Address - Street 1:1059 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3130
Mailing Address - Country:US
Mailing Address - Phone:717-397-7085
Mailing Address - Fax:717-390-2584
Practice Address - Street 1:1059 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-3130
Practice Address - Country:US
Practice Address - Phone:717-397-7085
Practice Address - Fax:717-390-2584
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OB-GYN OF LANCASTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-30
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP1001076G363LX0001X
PAMW010049367A00000X
PAMW008081L367A00000X
PAMW008560L367A00000X
PAMW008165L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007423330007Medicaid
PA102138829Medicaid