1902997349 NPI number — MARY KIMMITT LAXTON PA-C

Table of content: MARY KIMMITT LAXTON PA-C (NPI 1902997349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902997349 NPI number — MARY KIMMITT LAXTON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAXTON
Provider First Name:
MARY
Provider Middle Name:
KIMMITT
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902997349
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 EDGMONT AVE
Provider Second Line Business Mailing Address:
STE 1500
Provider Business Mailing Address City Name:
CHESTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19013-3962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANOVER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17331-2297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-988-0000
Provider Business Practice Location Address Fax Number:
717-782-5716
Provider Enumeration Date:
09/28/2006

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: 363A00000X , with the licence number:  MA002532L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: MA002532L , 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: MA002532L . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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