Provider Demographics
NPI:1558326868
Name:EGAN, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:EGAN
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 1:340 MAIN STREET
Mailing Address - Street 2:SUITE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-798-8012
Practice Address - Street 1:2100 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5615
Practice Address - Country:US
Practice Address - Phone:617-298-4632
Practice Address - Fax:617-296-6919
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA162501367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA0695Medicare ID - Type Unspecified