Provider Demographics
NPI:1588643472
Name:FEDORWICH, CHRISTY L (PA)
Entity type:Individual
Prefix:MS
First Name:CHRISTY
Middle Name:L
Last Name:FEDORWICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3986
Practice Address - Street 1:252 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6111
Practice Address - Country:US
Practice Address - Phone:717-270-3751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP00218800363A00000X
NY024817363A00000X
CT001613363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236007Medicaid
CT001613OtherPHYSICIAN LICENSE
NJ25MP00218800OtherSTATE
CT1064074OtherNCCPA LICENSE
NJ25MP00218800OtherSTATE