Provider Demographics
NPI:1366658502
Name:DECONCILIIS, GREGORY P (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:P
Last Name:DECONCILIIS
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:22 CHARLEMONT ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1908
Mailing Address - Country:US
Mailing Address - Phone:617-233-6804
Mailing Address - Fax:781-207-0204
Practice Address - Street 1:840 WINTER ST.
Practice Address - Street 2:BOSTON OUT-PATIENT SURGICAL SUITES, LLC
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:781-895-4908
Practice Address - Fax:781-895-4902
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MA1250363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical