Provider Demographics
NPI:1952794414
Name:DESTINE, NINDRA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NINDRA
Middle Name:
Last Name:DESTINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NINDRA
Other - Middle Name:
Other - Last Name:EUGENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY STREET
Practice Address - Street 2:SHAPIRO LOWER LEVEL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-638-6287
Practice Address - Fax:617-638-6284
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5317363A00000X
RIPA00822363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110112686AMedicaid