Basic Information
| Provider Information | |||||||||
| NPI: | 1962799817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STELLATO | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTOS | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 415258 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812801694 | ||||||||
| FaxNumber: | 7812766411 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021763225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812801694 | ||||||||
| FaxNumber: | 7812766411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA4188 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.