Provider Demographics
NPI:1679513873
Name:SALLEY, PATRICIA (PA-C)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:SALLEY
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 1:4190 CITY AVE
Mailing Address - Street 2:315
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-6844
Mailing Address - Fax:215-871-6932
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:315
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6844
Practice Address - Fax:215-871-6932
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002359363A00000X
PAOA002299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA129253E7HMedicare PIN