Basic Information
| Provider Information | |||||||||
| NPI: | 1558723536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | METKOWSKI | ||||||||
| FirstName: | AFTON | ||||||||
| MiddleName: | RENETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 N. BROAD STREET | ||||||||
| Address2: | BOYER PAVILION BLDG., 2ND FLOOR, SUITE 226A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2678963361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1316 W. ONTARIO ST | ||||||||
| Address2: | JONES HALL, 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008367536 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2016 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | MT220759 | PA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.