Provider Demographics
NPI:1275197337
Name:ANASTASIA, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:ANASTASIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 OLD ROAD TO NAC COR
Mailing Address - Street 2:CREDENTIALING DEPARTMENT SUITE 320
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4169
Mailing Address - Country:US
Mailing Address - Phone:617-952-5000
Mailing Address - Fax:
Practice Address - Street 1:300 1ST AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-3109
Practice Address - Country:US
Practice Address - Phone:617-952-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MARN2308066363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program