Provider Demographics
NPI:1093308520
Name:MOSGROVE, CAMERON THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CAMERON
Middle Name:THOMAS
Last Name:MOSGROVE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:WHITE 1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-724-4100
Mailing Address - Fax:617-726-7415
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WHITE 1
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-4100
Practice Address - Fax:617-726-7415
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MAPA8533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program