Provider Demographics
NPI:1467447300
Name:PECQUEX, NICOLE JARDIN (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JARDIN
Last Name:PECQUEX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JARDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 NEVINS ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3514
Mailing Address - Country:US
Mailing Address - Phone:617-789-2442
Mailing Address - Fax:617-789-4207
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-789-2442
Practice Address - Fax:617-789-4207
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219025208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2031370Medicaid
MAA36367Medicare ID - Type Unspecified
MA2031370Medicaid