Provider Demographics
NPI:1477734168
Name:STATHAM, ALLISON (PA)
Entity Type:Individual
Prefix:MS
First Name:ALLISON
Middle Name:
Last Name:STATHAM
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 1:15 PARKMAN ST
Mailing Address - Street 2:MGH WAC 440
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3117
Mailing Address - Country:US
Mailing Address - Phone:617-726-6100
Mailing Address - Fax:
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:MGH WAC 440
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2437363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical