Provider Demographics
NPI:1568160497
Name:MAYAMA, NELSON
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:MAYAMA
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 1:37 AGATE AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1106
Mailing Address - Country:US
Mailing Address - Phone:508-667-1657
Mailing Address - Fax:
Practice Address - Street 1:37 AGATE AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1106
Practice Address - Country:US
Practice Address - Phone:508-667-1657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2280631163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse