Provider Demographics
NPI:1447336599
Name:PERILLO, DOROTHY A (PA-C)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:A
Last Name:PERILLO
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 1:750 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-6835
Mailing Address - Country:US
Mailing Address - Phone:570-455-6385
Mailing Address - Fax:
Practice Address - Street 1:750 E BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6835
Practice Address - Country:US
Practice Address - Phone:570-455-6385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000784L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA086329Medicare ID - Type Unspecified
PA117703FUCMedicare UPIN