Provider Demographics
NPI:1063838258
Name:BOGDASARIAN, ROBERT M (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:BOGDASARIAN
Suffix:
Gender:M
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 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:
Practice Address - Street 1:460 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2442
Practice Address - Country:US
Practice Address - Phone:774-221-5135
Practice Address - Fax:774-221-5136
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105900AMedicaid