Provider Demographics
NPI:1962001693
Name:PRENDERGAST, JOSEPH (NP)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:NP
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-8515
Practice Address - Fax:508-334-6490
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309484363L00000X
MA2020066046363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care