Provider Demographics
NPI:1386602548
Name:NOTTLESON, ELIOT E (PA)
Entity type:Individual
Prefix:
First Name:ELIOT
Middle Name:E
Last Name:NOTTLESON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WINCHENDON
Mailing Address - State:MA
Mailing Address - Zip Code:01475-1820
Mailing Address - Country:US
Mailing Address - Phone:978-297-2311
Mailing Address - Fax:978-297-4173
Practice Address - Street 1:55 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINCHENDON
Practice Address - State:MA
Practice Address - Zip Code:01475-1820
Practice Address - Country:US
Practice Address - Phone:978-297-2311
Practice Address - Fax:978-297-4173
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP1832Medicare ID - Type Unspecified