Provider Demographics
NPI:1588986673
Name:THE PENNSYLVANIA STATE UNIVERSITY
Entity type:Organization
Organization Name:THE PENNSYLVANIA STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:PASKY
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CRNP
Authorized Official - Phone:814-898-6217
Mailing Address - Street 1:4701 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16563-4117
Mailing Address - Country:US
Mailing Address - Phone:814-898-6217
Mailing Address - Fax:814-898-6924
Practice Address - Street 1:4701 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16563-4117
Practice Address - Country:US
Practice Address - Phone:814-898-6217
Practice Address - Fax:814-898-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026142E261Q00000X
PAOS-013025261Q00000X
PASP-000395B261Q00000X
PAMD-054140L261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center