Provider Demographics
NPI:1114031739
Name:ST. GEORGE, KERRI DANIELLE (PA)
Entity type:Individual
Prefix:MS
First Name:KERRI
Middle Name:DANIELLE
Last Name:ST. GEORGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CAREW ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3405
Mailing Address - Country:US
Mailing Address - Phone:413-707-6460
Mailing Address - Fax:413-707-6440
Practice Address - Street 1:90 CAREW ST UNIT B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3405
Practice Address - Country:US
Practice Address - Phone:413-707-6460
Practice Address - Fax:413-707-6440
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1573Medicare ID - Type Unspecified
MAP43749Medicare UPIN