Healthcare Provider Details

I. General information

NPI: 1497395842
Provider Name (Legal Business Name): BRIAN THOMAS PELLICANO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BIRNIE AVE STE 201
SPRINGFIELD MA
01107-1121
US

IV. Provider business mailing address

300 BIRNIE AVE STE 201
SPRINGFIELD MA
01107-1121
US

V. Phone/Fax

Practice location:
  • Phone: 413-785-4666
  • Fax: 413-846-4756
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102074
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: