Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 74040 | MA |
Y | 2080P0204X | Pediatric Emergency Doctor | 74040 | MA |
NPI | 1225096605 |
---|---|
Provider Name | Dr. Anne M Stack |
First Address | Boston, MA 02115-5724 |
Second Address | Boston, MA 02115-5724 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 14/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3089890 | (05) | MA |
F31627 | (02) |