Provider Demographics
NPI:1750687778
Name:PATRUNO, JILL C (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:PATRUNO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CENTER ST
Mailing Address - Street 2:200 CENTER STREET
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-2772
Mailing Address - Country:US
Mailing Address - Phone:413-589-7176
Mailing Address - Fax:413-589-7710
Practice Address - Street 1:200 CENTER ST
Practice Address - Street 2:200 CENTER STREET
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-2772
Practice Address - Country:US
Practice Address - Phone:413-589-7176
Practice Address - Fax:413-589-7710
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA4124OtherPHYSICIAN ASSISTANT LICENSE