Basic Information
| Provider Information | |||||||||
| NPI: | 1801142526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUER DE MUENZBERG | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAUER | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| 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: | 105 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VALLEY VIEW | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179839423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706828026 | ||||||||
| FaxNumber: | 5706828043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA002898 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MA055654 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 247049F6K | 01 | PA | MEDICARE PTAN | OTHER |