Provider Demographics
NPI:1295889681
Name:PLYMOUTH, CARINE (NP, CRNA)
Entity type:Individual
Prefix:
First Name:CARINE
Middle Name:
Last Name:PLYMOUTH
Suffix:
Gender:F
Credentials:NP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 HOWLAND ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 YORK ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-1829
Practice Address - Country:US
Practice Address - Phone:781-344-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN201984363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099918AMedicaid
MA110099918BMedicaid
MAS400129870OtherMEDICARE
MA001684203OtherMEDICARE
MA110099918AMedicaid
MAS400387170OtherMEDICARE
MA001684201OtherMEDICARE