1306176821 NPI number — MISS ALISSA LYNNE MATECHAK COTA

Table of content: MISS ALISSA LYNNE MATECHAK COTA (NPI 1306176821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306176821 NPI number — MISS ALISSA LYNNE MATECHAK COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATECHAK
Provider First Name:
ALISSA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
COTA
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:
1306176821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 ELIAS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING BROOK TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18444-6238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-842-9436
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
956 E RAILROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYN MAWR
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19010-3831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-525-8412
Provider Business Practice Location Address Fax Number:
610-527-4236
Provider Enumeration Date:
01/05/2010

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: 224Z00000X , with the licence number:  OP005973 , 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)





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