Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208D00000X | General Practice Physician | 156198 | MA |
NPI | 1013946094 |
---|---|
Provider Name | Maximina Boutselis |
First Address | West Newbury, MA 01985-4201 |
Second Address | West Newbury, MA 01985-4201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2006 |
Last Update Date | 30/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0101290 | (05) | MA |
30200844 | (05) | NH |
H21856 | (02) |