Provider Demographics
NPI:1265554125
Name:WANGERIN, GAIL BEAVEN (PHD RN CS)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:BEAVEN
Last Name:WANGERIN
Suffix:
Gender:F
Credentials:PHD RN CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:599 CANAL ST
Mailing Address - Street 2:5TH FLOOR EAST
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840
Mailing Address - Country:US
Mailing Address - Phone:978-682-8881
Mailing Address - Fax:978-682-8872
Practice Address - Street 1:599 CANAL ST
Practice Address - Street 2:5TH FLOOR EAST
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840
Practice Address - Country:US
Practice Address - Phone:978-682-8881
Practice Address - Fax:978-682-8872
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA88312364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000037939OtherHEALTH NET
PN0147OtherBLUE CROSS
002253OtherHARVARD
MA1858088Medicaid
MA1898434Medicaid
1034440OtherNHP
332000Medicare UPIN
MA1898434Medicaid