MEDICARE: MR. GERALD A DAHLSTROM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA32	MA
2	363A00000X	Physician Assistant	32	MA

General Provider Information

NPI Number	:	1639144843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GERALD A DAHLSTROM PA-C

Provider Business Mailing Address
First Line	:	178 PUTNAM HILL RD
Second Line	:
City	:	SUTTON
State	:	MA
Zip	:	01590-1117
Country	:	US
Telephone Number	:	508-865-6217
Fax Number	:

Provider Business Practice Location Address
First Line	:	178 PUTNAM HILL RD
Second Line	:
City	:	SUTTON
State	:	MA
Zip	:	01590-1117
Country	:	US
Telephone Number	:	508-865-6217
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	11/15/2021

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