Provider Demographics
NPI:1184725038
Name:BOGAL, CAROLYN B (NP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:B
Last Name:BOGAL
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 1:7 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-3120
Mailing Address - Country:US
Mailing Address - Phone:508-728-1905
Mailing Address - Fax:
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-894-0590
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN153493363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400469060OtherMEDICARE
MA110020132AMedicaid