Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 217111 | MA |
NPI | 1003854399 |
---|---|
Provider Name | Amanda Klein |
First Address | Somerville, MA 02145-2935 |
Second Address | Somerville, MA 02145-2935 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2006 |
Last Update Date | 01/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2111047 | (05) | MA |