Provider Demographics
NPI:1861472987
Name:PRIMITERIO, VIDAL (PA)
Entity type:Individual
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First Name:VIDAL
Middle Name:
Last Name:PRIMITERIO
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:25 MARSTON ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2310
Mailing Address - Country:US
Mailing Address - Phone:978-258-1057
Mailing Address - Fax:978-258-1520
Practice Address - Street 1:25 MARSTON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2310
Practice Address - Country:US
Practice Address - Phone:978-258-1057
Practice Address - Fax:978-258-1520
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2014-09-10
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Provider Licenses
StateLicense IDTaxonomies
MA1813363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY10064Medicaid
MAY10064Medicaid