Provider Demographics
NPI:1205857000
Name:WONDOLOWSKI, JULIE M (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:WONDOLOWSKI
Suffix:
Gender:F
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 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-739-2278
Practice Address - Street 1:701 ENFIELD ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-2961
Practice Address - Country:US
Practice Address - Phone:860-741-6058
Practice Address - Fax:860-741-6864
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1299363AM0700X
CT001474363AM0700X
MAPA1299363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P39638Medicare UPIN
AP1539Medicare ID - Type Unspecified