Provider Demographics
NPI:1699118364
Name:LANCIOTTI, KORI (PA-C)
Entity type:Individual
Prefix:MS
First Name:KORI
Middle Name:
Last Name:LANCIOTTI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KORI
Other - Middle Name:
Other - Last Name:IMONDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-726-5201
Mailing Address - Fax:617-726-7667
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1975363A00000X
MA4620363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3127183Medicaid