Provider Demographics
NPI:1801434154
Name:MALDONADO, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:MALDONADO
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 1:819 WORCESTER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01151-1056
Mailing Address - Country:US
Mailing Address - Phone:413-304-2501
Mailing Address - Fax:413-789-0290
Practice Address - Street 1:819 WORCESTER ST STE 1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01151-1056
Practice Address - Country:US
Practice Address - Phone:413-304-2501
Practice Address - Fax:413-789-0290
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MAPA8112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program