Provider Demographics
NPI:1730375403
Name:MASTRONUNZIO, KATE B (PA-C)
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:B
Last Name:MASTRONUNZIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:JOHNSON MEMORIAL HOSPITAL EMERGENCY ROOM
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-684-8185
Practice Address - Fax:860-684-8285
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400007476Medicare PIN
CT970002539Medicare PIN