Provider Demographics
NPI:1083200166
Name:SUTHERLAND, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-1834
Mailing Address - Country:US
Mailing Address - Phone:203-947-3054
Mailing Address - Fax:
Practice Address - Street 1:397 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1218
Practice Address - Country:US
Practice Address - Phone:508-688-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program