Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | S44443453 | MA |
NPI | 1720544364 |
---|---|
Provider Name | Bridget Looney |
First Address | Woburn, MA 01801-5152 |
Second Address | Woburn, MA 01801-5152 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/02/2019 |
Last Update Date | 19/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S44443453 | LISENCE (01) | MA |