Provider Demographics
NPI:1134318090
Name:PUCILLO, ANGELO (PA)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:PUCILLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GILL ST
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1728
Mailing Address - Country:US
Mailing Address - Phone:781-937-4522
Mailing Address - Fax:781-937-4510
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3225
Practice Address - Country:US
Practice Address - Phone:781-979-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2423363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0003723Medicare PIN