Provider Demographics
NPI:1407524697
Name:NIYOGUSABA, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:NIYOGUSABA
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 1:15 PARKMAN ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3117
Mailing Address - Country:US
Mailing Address - Phone:781-485-1000
Mailing Address - Fax:781-286-5418
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:781-485-1000
Practice Address - Fax:781-286-5418
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program