Provider Demographics
NPI:1992850747
Name:JOHN, JANICE N (PA)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:N
Last Name:JOHN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2524
Mailing Address - Country:US
Mailing Address - Phone:857-654-1000
Mailing Address - Fax:857-654-1094
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2524
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:857-654-1094
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1814Medicare ID - Type UnspecifiedMEDICARE
MAP68731Medicare UPIN