1770858805 NPI number — MICHELLE A POMIDOR CRNP

Table of content: MICHELLE A POMIDOR CRNP (NPI 1770858805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770858805 NPI number — MICHELLE A POMIDOR CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POMIDOR
Provider First Name:
MICHELLE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILLIPPY
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770858805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 N 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEMOYNE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17043-1440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-234-2561
Provider Business Mailing Address Fax Number:
717-236-1121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 SOUTH FRONT STREET
Provider Second Line Business Practice Location Address:
6TH FL BMA
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17104-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-988-9370
Provider Business Practice Location Address Fax Number:
717-703-0154
Provider Enumeration Date:
03/22/2012

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: 363LA2100X , with the licence number:  SP011896 , 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: 1609534 . This is a "GATEWAY MEDICARE ASSURED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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