1780985630 NPI number — AMANDA LYNNE HATALSKI PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780985630 NPI number — AMANDA LYNNE HATALSKI PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATALSKI
Provider First Name:
AMANDA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALKER
Provider Other First Name:
AMANDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780985630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 SPRUCE STREET
Provider Second Line Business Mailing Address:
4 SILVERSTEIN
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-4206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-662-2626
Provider Business Mailing Address Fax Number:
215-349-8195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 SPRUCE STREET
Provider Second Line Business Practice Location Address:
4 SILVERSTEIN
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-662-2626
Provider Business Practice Location Address Fax Number:
215-349-8195
Provider Enumeration Date:
11/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  MA053418 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23-2359401 . This is a "MAIN LINE HEALTHCARE TAX ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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