MEDICARE: MS. PAMELA R GERVAIS PA

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	2403	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2403	OTHER	MA	PHYSICIAN ASSISTANT LICENSE

General Provider Information

NPI Number	:	1417110297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAMELA R GERVAIS PA

Provider Business Mailing Address
First Line	:	45 COLPITTS RD
Second Line	:
City	:	WESTON
State	:	MA
Zip	:	02493-1546
Country	:	US
Telephone Number	:	781-642-8877
Fax Number	:	781-642-1117

Provider Business Practice Location Address
First Line	:	45 COLPITTS RD
Second Line	:
City	:	WESTON
State	:	MA
Zip	:	02493-1546
Country	:	US
Telephone Number	:	781-642-8877
Fax Number	:	781-642-1117

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

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	07/02/2008

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