1366980302 NPI number — KRISTIN FARRELL WASON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366980302 NPI number — KRISTIN FARRELL WASON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASON
Provider First Name:
KRISTIN
Provider Middle Name:
FARRELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WENSLEY
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
FARRELL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
N.P.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366980302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
SECOND FLOOR, SUITE 2027D
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-414-4176
Provider Business Mailing Address Fax Number:
617-414-4231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 ALBANY ST
Provider Second Line Business Practice Location Address:
GENERAL INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-414-5951
Provider Business Practice Location Address Fax Number:
617-414-9157
Provider Enumeration Date:
02/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  RN2262692 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: RN2262692 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110122621A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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