Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 132516 | MA |
NPI | 1003983511 |
---|---|
Provider Name | Matthew J Bellanich |
First Address | Charlestown, MA 02129-9142 |
Second Address | Boston, MA 02114 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S61655 | (02) |