Healthcare Provider Details

I. General information

NPI: 1477172120
Provider Name (Legal Business Name): VASIN PALANUKORN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WATER ST STE 1A
ARLINGTON MA
02476-4814
US

IV. Provider business mailing address

11 PARK ST APT 5
BROOKLINE MA
02446-6210
US

V. Phone/Fax

Practice location:
  • Phone: 781-648-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8317
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: