Provider Demographics
NPI:1962779447
Name:EVANOFF-JURKOVIC, MARGUERITE (DO)
Entity type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:
Last Name:EVANOFF-JURKOVIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:5401 PEACH ST
Practice Address - Street 2:SUITE 3500
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2601
Practice Address - Country:US
Practice Address - Phone:814-868-2179
Practice Address - Fax:814-868-2346
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007988204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013065700005Medicaid
PA396967US8Medicare PIN