Provider Demographics
NPI:1710966924
Name:POLSON, KATHLEEN (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:POLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 W NEWTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1203
Mailing Address - Country:US
Mailing Address - Phone:617-536-0031
Mailing Address - Fax:617-632-3408
Practice Address - Street 1:44 BINNEY ST
Practice Address - Street 2:SW 540
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6013
Practice Address - Country:US
Practice Address - Phone:617-632-5204
Practice Address - Fax:617-632-3408
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ06585Medicare UPIN
MANP4383Medicare ID - Type Unspecified