Provider Demographics
NPI:1619441946
Name:MENON, VIDHU VINOD
Entity Type:Individual
Prefix:
First Name:VIDHU
Middle Name:VINOD
Last Name:MENON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NORTHEASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-3128
Mailing Address - Country:US
Mailing Address - Phone:603-882-3616
Mailing Address - Fax:603-595-7414
Practice Address - Street 1:45 HIGH ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3312
Practice Address - Country:US
Practice Address - Phone:603-821-7788
Practice Address - Fax:603-821-5620
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH057311-23363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology