Provider Demographics
NPI:1841238201
Name:MANSUR, TARINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:TARINA
Middle Name:M
Last Name:MANSUR
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 1:45 PALMER ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1834
Mailing Address - Country:US
Mailing Address - Phone:978-970-1607
Mailing Address - Fax:978-970-1115
Practice Address - Street 1:45 PALMER ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1834
Practice Address - Country:US
Practice Address - Phone:978-970-1607
Practice Address - Fax:978-970-1115
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1363363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP50391Medicare UPIN
MAAP1627Medicare ID - Type Unspecified