Basic Information
| Provider Information | |||||||||
| NPI: | 1083769111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLEGRINO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 LOCUST ST | ||||||||
| Address2: | COOLEY DICKINSON HOSPITAL, DEPT OF EMERGENCY MEDICINE | ||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010602052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135822363 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 LOCUST ST | ||||||||
| Address2: | COOLEY DICKINSON HOSPITAL, DEPT OF EMERGENCY MEDICINE | ||||||||
| City: | NORTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010602052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135822363 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | AP2303 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 0661 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00730832 | 01 | NH | RAILROAD MEDICARE | OTHER | 30336642 | 05 | NH | MEDICAID |