Basic Information
| Provider Information | |||||||||
| NPI: | 1790921831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THABET | ||||||||
| FirstName: | JANITZA | ||||||||
| MiddleName: | CORTES | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORTES | ||||||||
| OtherFirstName: | JANITZA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3640 MAIN ST | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137390669 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3640 MAIN ST | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137390669 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2008 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 282694 | MA | N | Nursing Service Providers | Registered Nurse | 363A00000X | PA4980 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1301071 | 01 | MA | GROUP NUMBER | OTHER |