Provider Demographics
NPI:1629735790
Name:CHURCHILL, VICTORIA B (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:B
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:BELLE
Other - Last Name:CHURCHILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:336-676-2551
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST, STE 3B
Practice Address - Street 2:SHAPIRO BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-8485
Practice Address - Fax:617-414-7372
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA100586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant