Provider Demographics
NPI:1790476166
Name:BERTRAND, VANESSA (PA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BERTRAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST, LOWER LEVEL
Practice Address - Street 2:SHAPIRO BUILDING
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-638-6287
Practice Address - Fax:617-638-6284
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPA9455363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110200400AMedicaid