Provider Demographics
NPI:1881834174
Name:DETWILER, MEREDITH BRASSARD (NP)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:BRASSARD
Last Name:DETWILER
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 1:105 WEBSTER ST STE 8
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1227
Mailing Address - Country:US
Mailing Address - Phone:781-754-6545
Mailing Address - Fax:781-536-0016
Practice Address - Street 1:105 WEBSTER ST STE 8
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1227
Practice Address - Country:US
Practice Address - Phone:781-754-6545
Practice Address - Fax:781-536-0016
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA268698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110091419AMedicaid
P00730430Medicare PIN