Provider Demographics
NPI:1942742390
Name:MANCUSO, JULIA MICHAEL (PA-C, MS, ATC)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:MICHAEL
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:PA-C, MS, ATC
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:MICHAEL
Other - Last Name:CARNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, LAT
Mailing Address - Street 1:1313 WASHINGTON ST APT 518
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2170
Mailing Address - Country:US
Mailing Address - Phone:774-249-3395
Mailing Address - Fax:
Practice Address - Street 1:1313 WASHINGTON ST APT 518
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2170
Practice Address - Country:US
Practice Address - Phone:774-249-3395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty