Provider Demographics
NPI:1144385675
Name:O'DONNELL, KEVIN B (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:230 WORCESTER ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5420
Mailing Address - Country:US
Mailing Address - Phone:761-765-4711
Mailing Address - Fax:781-431-5329
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:761-765-4711
Practice Address - Fax:781-431-5329
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2021-01-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS61769Medicare UPIN
MAAP0888Medicare ID - Type Unspecified