Provider Demographics
NPI:1871690958
Name:KOLAK, GINA C (NP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:C
Last Name:KOLAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAHEY CLINIC
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8640
Mailing Address - Fax:781-744-3751
Practice Address - Street 1:LAHEY CLINIC
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8640
Practice Address - Fax:781-744-3751
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213866363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0321648Medicaid
MA0321648Medicaid
MANP4318Medicare ID - Type Unspecified