Basic Information
| Provider Information | |||||||||
| NPI: | 1730595828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERTIN | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | RYAN | ||||||||
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| OtherLastName: | RYAN | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137943909 | ||||||||
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| Practice Location | |||||||||
| Address1: | 48 SANDERSON STREET | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013012613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137732626 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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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 | 363A00000X | PA5036 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA5036 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.