Basic Information
| Provider Information | |||||||||
| NPI: | 1528074911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5 CHERYL ST | ||||||||
| Address2: | |||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708291718 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1111 E. END BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES-BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708243521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNOWLES | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED RESPIRATORY THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5708243521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RRT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | YM-003940-L | PA | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.