Provider Demographics
NPI:1306352430
Name:CHADDERDON, PATRICIA ROSE (PTA COTA/L)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ROSE
Last Name:CHADDERDON
Suffix:
Gender:F
Credentials:PTA COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8206 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COGAN STATION
Mailing Address - State:PA
Mailing Address - Zip Code:17728-8522
Mailing Address - Country:US
Mailing Address - Phone:570-971-3332
Mailing Address - Fax:
Practice Address - Street 1:2140 WARRENSVILLE RD
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-9621
Practice Address - Country:US
Practice Address - Phone:570-433-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP005794208100000X
PATE1002554208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation