Provider Demographics
NPI:1003871898
Name:MAHONEY, CORINNE (PA)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 RESNIK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4842
Mailing Address - Country:US
Mailing Address - Phone:781-934-2400
Mailing Address - Fax:781-934-3930
Practice Address - Street 1:111 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3903
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1006363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP57595Medicare UPIN
MAAP1701Medicare ID - Type Unspecified