Basic Information
| Provider Information | |||||||||
| NPI: | 1013955509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANISCALCO | ||||||||
| FirstName: | JODI | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419218 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022419218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556919890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 W SILVER ST | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010853628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135682811 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 01/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1064 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970016569 | 01 | MA | RAILROAD MEDICARE | OTHER |