Provider Demographics
NPI:1003825316
Name:THERIAULT, LINDA (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1000
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:2ND FLOOR SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1002
Practice Address - Country:US
Practice Address - Phone:413-794-7246
Practice Address - Fax:413-794-0198
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA694363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical