Provider Demographics
NPI:1912907098
Name:STAUB, PERPETUA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:PERPETUA
Middle Name:ANN
Last Name:STAUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 GRANDVIEW RD
Mailing Address - Street 2:BUILDING B, SUITE 1
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-9134
Mailing Address - Country:US
Mailing Address - Phone:717-316-6967
Mailing Address - Fax:717-316-6994
Practice Address - Street 1:3130 GRANDVIEW RD
Practice Address - Street 2:BUILDING B, SUITE 1
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-9134
Practice Address - Country:US
Practice Address - Phone:717-316-6967
Practice Address - Fax:717-316-6994
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425196207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101168823Medicaid
PAF61399Medicare UPIN
PA101168823Medicaid