Provider Demographics
NPI:1366006330
Name:FUKUDA, THERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FUKUDA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BOWDOIN ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4238
Mailing Address - Country:US
Mailing Address - Phone:802-999-3882
Mailing Address - Fax:
Practice Address - Street 1:43 BOWDOIN ST APT 2F
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4238
Practice Address - Country:US
Practice Address - Phone:802-999-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA092289Medicaid