1366928756 NPI number — CARMEN SHAW WILSON AUD

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 1366928756 NPI number — CARMEN SHAW WILSON AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
CARMEN
Provider Middle Name:
SHAW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAW
Provider Other First Name:
CARMEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366928756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 BROOKLINE AVE BLDG GROUP
Provider Second Line Business Mailing Address:
SHAPIRO BUILDING, GROUND FLOOR, SUITE SCG63
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-5491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-632-7500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BROOKLINE AVENUE
Provider Second Line Business Practice Location Address:
SHAPIRO BUILDING, GROUND FLOOR, SUITE SCG63
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-632-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2018

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: 231H00000X , with the licence number:  4731 , 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: 110171698A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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