Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | LP03299 | RI |
N | 208600000X | Surgeon | LP03299 | RI |
Y | 208800000X | Urologist | 283649 | MA |
NPI | 1053799726 |
---|---|
Provider Name | Jennifer Fantasia |
First Address | Boston, MA 02241-5348 |
Second Address | Worcester, MA 01605-2726 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2015 |
Last Update Date | 27/10/2020 |