Provider Demographics
NPI:1639144843
Name:DAHLSTROM, GERALD A (PA-C)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:A
Last Name:DAHLSTROM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 PUTNAM HILL RD
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:MA
Mailing Address - Zip Code:01590-1117
Mailing Address - Country:US
Mailing Address - Phone:508-865-6217
Mailing Address - Fax:
Practice Address - Street 1:178 PUTNAM HILL RD
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:MA
Practice Address - Zip Code:01590-1117
Practice Address - Country:US
Practice Address - Phone:508-865-6217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA32363AM0700X
MA32363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP97076Medicare UPIN
MAAP200301Medicare PIN