Provider Demographics
NPI:1790116671
Name:WICHOWSKI, KAYLA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WICHOWSKI
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 1:18 ACADIA PARK
Mailing Address - Street 2:APT. 3
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3506
Mailing Address - Country:US
Mailing Address - Phone:413-454-8244
Mailing Address - Fax:
Practice Address - Street 1:103 MYRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1598
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0100
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPA4898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant