Provider Demographics
NPI:1689737850
Name:DOHERTY, KEVIN (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 SANDWICH ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2183
Mailing Address - Country:US
Mailing Address - Phone:508-746-2000
Mailing Address - Fax:781-341-8544
Practice Address - Street 1:275 SANDWICH ROAD
Practice Address - Street 2:JORDAN HOSPITAL
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360
Practice Address - Country:US
Practice Address - Phone:781-344-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250820367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA1220Medicare PIN