Provider Demographics
NPI:1063448710
Name:BERUBE, JUDITH A (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:BERUBE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5204
Mailing Address - Country:US
Mailing Address - Phone:508-862-5650
Mailing Address - Fax:508-778-4753
Practice Address - Street 1:34 PARK ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5204
Practice Address - Country:US
Practice Address - Phone:508-862-5650
Practice Address - Fax:508-778-4753
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA179473363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP3835OtherBCBS PROVIDER NUMBER
MAP63750Medicare UPIN
NP3835Medicare ID - Type Unspecified