Provider Demographics
NPI:1295798437
Name:ANTOS, DEBORAH (PA)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:ANTOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8267
Mailing Address - Fax:
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA273363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS24109Medicare UPIN
MAAP0089Medicare PIN