Provider Demographics
NPI:1598745978
Name:OBORNE, KAMMILLE (PA)
Entity Type:Individual
Prefix:MS
First Name:KAMMILLE
Middle Name:
Last Name:OBORNE
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 1:3640 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1145
Mailing Address - Country:US
Mailing Address - Phone:413-785-5321
Mailing Address - Fax:413-731-7130
Practice Address - Street 1:3640 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1145
Practice Address - Country:US
Practice Address - Phone:413-785-5321
Practice Address - Fax:413-731-7130
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA907363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1428Medicare ID - Type Unspecified
MAP26619Medicare UPIN
970018113Medicare PIN