Provider Demographics
NPI:1568785954
Name:WIENER FOX, GRETA I (NP)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:I
Last Name:WIENER FOX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 ORNAC
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3317
Mailing Address - Country:US
Mailing Address - Phone:978-371-0302
Mailing Address - Fax:978-371-2240
Practice Address - Street 1:59 ORNAC
Practice Address - Street 2:SUITE 1
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3317
Practice Address - Country:US
Practice Address - Phone:978-371-0302
Practice Address - Fax:978-371-2240
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA164832363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0365190Medicaid
MANP4484OtherBLUE CROSS BLUE SHIELD
MANP4484OtherBLUE CROSS BLUE SHIELD