Provider Demographics
NPI:1235287905
Name:WASSERMAN, STANLEY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5804
Mailing Address - Country:US
Mailing Address - Phone:617-733-3235
Mailing Address - Fax:617-726-1821
Practice Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - Street 2:55 FRUIT STREET, BULFINCH 119
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-1861
Practice Address - Fax:617-726-1821
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA423363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical