Provider Demographics
NPI:1821664426
Name:KONDROTAS, GABRIEL PAUL (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:PAUL
Last Name:KONDROTAS
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:MA
Mailing Address - Zip Code:01005-0698
Mailing Address - Country:US
Mailing Address - Phone:978-551-5645
Mailing Address - Fax:
Practice Address - Street 1:179 EVERETT RD
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:MA
Practice Address - Zip Code:01005-8944
Practice Address - Country:US
Practice Address - Phone:978-551-5645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29122255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer