1366980302 NPI number — KRISTIN FARRELL WASON

Table of content: KRISTIN FARRELL WASON (NPI 1366980302)

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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