Provider Demographics
NPI:1588995468
Name:PELLETIER, PHILIP A (MSN, NP-C)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD STE 180
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5255
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:
Practice Address - Street 1:500 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1278
Practice Address - Country:US
Practice Address - Phone:508-973-2216
Practice Address - Fax:508-973-1305
Is Sole Proprietor?:No
Enumeration Date:2010-01-17
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN232943363L00000X
RIAPRN00414363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner