Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | OS014434 | PA |
NPI | 1184862427 |
---|---|
Provider Name | Jacob A Dicesare |
First Address | Bovard, PA 15619-0007 |
Second Address | Greensburg, PA 15601-7900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2009 |
Last Update Date | 08/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
102533207 0001 | (05) | PA |