Provider Demographics
NPI:1891026506
Name:MCGOVERN, TRICIA L
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:PATRICIA
Other - Last Name:MCGOVERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3350 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-9338
Practice Address - Fax:413-794-9754
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225188363LA2200X
MARN225188363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily