Provider Demographics
NPI:1093364895
Name:PROTOSEVICH, ALEXANDER GEORGE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:GEORGE
Last Name:PROTOSEVICH
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 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-6040
Mailing Address - Fax:
Practice Address - Street 1:250 CEDA RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:NH
Practice Address - Zip Code:03603-4511
Practice Address - Country:US
Practice Address - Phone:603-826-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8061363A00000X
VT055.0031434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty