Provider Demographics
NPI:1639261290
Name:GHOBRIAL, IRENE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:IRENE
Middle Name:
Last Name:GHOBRIAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 WINTER ST
Mailing Address - Street 2:ATTN: BOSTON SPORTS & SHOULDER CENTER
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1433
Mailing Address - Country:US
Mailing Address - Phone:781-890-2133
Mailing Address - Fax:781-890-2177
Practice Address - Street 1:840 WINTER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1433
Practice Address - Country:US
Practice Address - Phone:781-890-2133
Practice Address - Fax:781-890-2177
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA2222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant