Provider Demographics
NPI:1104270834
Name:PREMIER DERMATOLOGY
Entity type:Organization
Organization Name:PREMIER DERMATOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYPAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KWOKA
Authorized Official - Suffix:
Authorized Official - Credentials:MSM
Authorized Official - Phone:302-633-7550
Mailing Address - Street 1:537 STANTON CHRISTIANA RD
Mailing Address - Street 2:SUITES 107,111,207 & 209
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2146
Mailing Address - Country:US
Mailing Address - Phone:302-633-7550
Mailing Address - Fax:
Practice Address - Street 1:537 STANTON CHRISTIANA RD
Practice Address - Street 2:SUITES 107,111,207 & 209
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2146
Practice Address - Country:US
Practice Address - Phone:302-633-7550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0001054OtherDIVISION OF PROFESSIONAL REGULATION LICENSE