Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | TRN 19940 | FL |
Y | 207QA0505X | Family Doctor - Adult Medicine | 270083 | MA |
NPI | 1235543794 |
---|---|
Provider Name | Sasha Gittens |
First Address | Brockton, MA 02301-4042 |
Second Address | Brockton, MA 02301-4042 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2014 |
Last Update Date | 17/03/2018 |