Provider Demographics
NPI:1326027251
Name:CUSIMANO, TEHAN C (PA)
Entity Type:Individual
Prefix:
First Name:TEHAN
Middle Name:C
Last Name:CUSIMANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-885-9737
Mailing Address - Fax:508-885-6189
Practice Address - Street 1:407 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:MA
Practice Address - Zip Code:01562
Practice Address - Country:US
Practice Address - Phone:508-885-9737
Practice Address - Fax:508-885-6139
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
043058466002OtherTRICARE CHAMPUS
57118OtherFALLON COMM. HEALTH PLAN
042472266OtherTHREE RIVERS
P00005836OtherRAILROAD MEDICARE
8301421OtherEVERCARE
AP1906OtherMEDICARE B
P83987Medicare UPIN
042472266OtherTHREE RIVERS