Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 237016 | MA |
Y | 207YS0123X | Facial Plastic Surgeon | 237016 | MA |
NPI | 1023057031 |
---|---|
Provider Name | Jaimie Derosa |
First Address | Boston, MA 02116-3084 |
Second Address | Boston, MA 02116-3084 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2006 |
Last Update Date | 24/05/2013 |