Provider Demographics
NPI:1245698190
Name:MANCUSO, STEPHEN BARTLEY
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BARTLEY
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PEDERZINI DR
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 PEDERZINI DR
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-1426
Practice Address - Country:US
Practice Address - Phone:508-740-6376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2298943163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics