NPI |
1407429236 |
The middle name of the authorized official. |
Entity Type Code |
1 |
The title or position of the authorized official. |
Provider Last Name Legal Name |
CARROLL |
The 10-position telephone number of the authorized official. |
Provider First Name |
ROBB |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Credential Text |
PA-C |
|
Provider First Line Business Practice Location Address |
82 BROWN ST UNIT 4 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Provider Business Practice Location Address City Name |
WALTHAM |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Provider Business Practice Location Address State Name |
MA |
|
Provider Business Practice Location Address Postal Code |
024533988 |
|
Provider Business Practice Location Address Country Code If outside U S |
US |
|
Provider Business Practice Location Address Telephone Number |
9787262357 |
|
Provider Enumeration Date |
7/20/2021 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
7/20/2021 |
The date that a record was last updated or changed. |
Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Taxonomy Code 1 |
390200000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
NPI Certification Date |
7/20/2021 |
|