Provider Demographics
NPI:1134189905
Name:KOVALCHICK, FRED D (PA C)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:D
Last Name:KOVALCHICK
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:10 TRIEBLE DR
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-7054
Practice Address - Country:US
Practice Address - Phone:570-996-2700
Practice Address - Fax:570-996-2711
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA002483L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P98259Medicare UPIN
PA077003Medicare ID - Type Unspecified