Basic Information
| Provider Information | |||||||||
| NPI: | 1619916111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECKARD | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | GINGRICH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GINGRICH | ||||||||
| OtherFirstName: | BETH | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 SUSQUEHANNA VALLEY MALL DR STE A | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178709148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703747852 | ||||||||
| FaxNumber: | 5703747932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP005262B | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | RN266917L | PA | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1031841380001 | 05 | PA | MEDICAID |