Basic Information
| Provider Information | |||||||||
| NPI: | 1831432392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAFATA | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PENN SQUARE EAST | ||||||||
| Address2: | 9TH FLOOR NORTH TOWER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259200 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 N DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175445511 | ||||||||
| FaxNumber: | 7175445333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD462061 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1033472890001 | 05 | PA | MEDICAID |