Provider Demographics
NPI:1083769111
Name:PELLEGRINO, ANTHONY MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:PELLEGRINO
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 1:47 ALLEN RD DEPT OF
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1322
Mailing Address - Country:US
Mailing Address - Phone:508-633-2466
Mailing Address - Fax:
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0661363AM0700X
MAAP2303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30336642Medicaid
NHP00730832OtherRAILROAD MEDICARE
NHP00730832OtherRAILROAD MEDICARE
NH000077802Medicare PIN