Provider Demographics
NPI:1710549761
Name:WONSOR, DORISANNE YLLENA (PA-C)
Entity Type:Individual
Prefix:
First Name:DORISANNE
Middle Name:YLLENA
Last Name:WONSOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DORISANNE
Other - Middle Name:YLENA
Other - Last Name:RAGON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:17 SHANLEY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5450
Practice Address - Country:US
Practice Address - Phone:516-473-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-30
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant