Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 264803 | MA |
NPI | 1003175910 |
---|---|
Provider Name | Lidya H Wlasiuk |
First Address | Boston, MA 02118-2371 |
Second Address | Boston, MA 02118-4001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2012 |
Last Update Date | 26/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110102696A | (05) | MA |