Provider Demographics
NPI:1962936336
Name:PETTINATO, ELISSA (PA-C)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:PETTINATO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5443 HOUGHTON PL
Mailing Address - Street 2:APT. 1
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2816
Mailing Address - Country:US
Mailing Address - Phone:814-227-8403
Mailing Address - Fax:
Practice Address - Street 1:561 FAIRTHORNE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2412
Practice Address - Country:US
Practice Address - Phone:800-235-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004035363A00000X
NJ25MP00429700363A00000X
PAMA058812363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant