Basic Information
| Provider Information | |||||||||
| NPI: | 1467824722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARNESI | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 OLD LANCASTER ROAD | ||||||||
| Address2: | SUITE #250 | ||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190103239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105423300 | ||||||||
| FaxNumber: | 6105423320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2015 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA057693 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.