Provider Demographics
NPI:1548211659
Name:FELLOWS, BRIAN (NP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FELLOWS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 930
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:978-825-7124
Mailing Address - Fax:978-741-3890
Practice Address - Street 1:35 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-825-7124
Practice Address - Fax:978-741-3890
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213260363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0701688Medicaid
MANP4869Medicare ID - Type Unspecified
MA0701688Medicaid