Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 1110 | MA |
NPI | 1629125851 |
---|---|
Provider Name | Dr. Randall Will Ferrell |
First Address | Arlington, MA 02474-8613 |
Second Address | Arlington, MA 02474-8613 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Y35760 | BLUE CROSS BLUE SHIELD (01) | MA |