Provider Demographics
NPI:1487088241
Name:AVILES, STEPHANIE SAAL (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SAAL
Last Name:AVILES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:SAAL
Other - Last Name:AVILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:SPRINGFIELD MEDICAL ASSOCIATES, INC
Mailing Address - Street 2:2150 MAIN STREET
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:ENFIELD MEDICAL ASSOCIATES
Practice Address - Street 2:701 ENFIELD STREET
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-741-6058
Practice Address - Fax:413-733-5860
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA-4817363A00000X
MAPA4817363A00000X
MA5910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110110336AMedicaid