Provider Demographics
NPI:1821576935
Name:SELWYN, SIMON MAURICE SEBASTIAN (CNP)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:MAURICE SEBASTIAN
Last Name:SELWYN
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 WAVERLY OAKS RD STE 416
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8401
Mailing Address - Country:US
Mailing Address - Phone:617-596-1975
Mailing Address - Fax:781-735-0457
Practice Address - Street 1:465 WAVERLY OAKS RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8438
Practice Address - Country:US
Practice Address - Phone:617-596-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2284419363LP0808X
MARN2284419163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2284419OtherNURSING REGISTRATION BOARD