Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 80633 | MA |
NPI | 1184614414 |
---|---|
Provider Name | Agnes Virga |
First Address | Acton, MA 01720-3739 |
Second Address | Acton, MA 01720-3739 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3155706 | (05) | MA |
G27466 | (02) | MA |