Provider Demographics
NPI:1801860895
Name:KUTZER, PAMELA D (NP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:KUTZER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4051
Mailing Address - Country:US
Mailing Address - Phone:508-765-9771
Mailing Address - Fax:508-764-2448
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-9771
Practice Address - Fax:508-764-2448
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN223639363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0706728Medicaid
MANP1196Medicare PIN
MA0706728Medicaid