Provider Demographics
NPI: | 1619071099 |
---|---|
Name: | GREGSON, EVELYN MARY (NP) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | EVELYN |
Middle Name: | MARY |
Last Name: | GREGSON |
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: | 38 OAKES AVENUE |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTHBRIDGE |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 01550-4012 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-765-9522 |
Mailing Address - Fax: | 508-764-7870 |
Practice Address - Street 1: | 38 OAKES AVE |
Practice Address - Street 2: | |
Practice Address - City: | SOUTHBRIDGE |
Practice Address - State: | MA |
Practice Address - Zip Code: | 01550-4012 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-765-9522 |
Practice Address - Fax: | 508-764-7870 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-07 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 111473 | 363LA2200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 51977 | Other | FALLON COMMUNITY HEALTHCA |
MA | NP1383 | Medicare ID - Type Unspecified | MEDICARE PROVIDER NUMBER |
MA | 51977 | Other | FALLON COMMUNITY HEALTHCA |