Provider Demographics
NPI:1548218431
Name:FANTEGROSSI, JOHN P (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:FANTEGROSSI
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 1:34 PHILLIP DR
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02019-1112
Mailing Address - Country:US
Mailing Address - Phone:508-966-1057
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-7721
Practice Address - Fax:617-739-8632
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229328363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner