=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013622018
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALANNA SERVANT PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2023
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 MAIN ST SUITE 4D
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01107-1112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-794-8336
-----------------------------------------------------
Fax | 413-794-7345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 CHESTNUT STREET 2ND FLOOR
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01199-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-794-3909
-----------------------------------------------------
Fax | 413-794-1629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9191
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------