Provider Demographics
NPI:1780069310
Name:THIBODEAU, ADRIENNE (PA-C)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:BOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 HOSPITAL DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-6632
Mailing Address - Country:US
Mailing Address - Phone:413-540-5048
Mailing Address - Fax:
Practice Address - Street 1:2 HOSPITAL DR
Practice Address - Street 2:SUITE 203
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-6632
Practice Address - Country:US
Practice Address - Phone:413-540-5048
Practice Address - Fax:413-540-5049
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5482363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical