Provider Demographics
NPI:1275614471
Name:REARDON, ROSEMARY (PAC)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ROSEMARY
Other - Middle Name:
Other - Last Name:NOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 SCOBEE CIR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4887
Mailing Address - Country:US
Mailing Address - Phone:508-747-0711
Mailing Address - Fax:508-747-0011
Practice Address - Street 1:1 SCOBEE CIR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4887
Practice Address - Country:US
Practice Address - Phone:508-747-0711
Practice Address - Fax:508-747-0011
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007292P05Medicare ID - Type Unspecified
VAQ42301Medicare UPIN