Healthcare Provider Details

I. General information

NPI: 1063277465
Provider Name (Legal Business Name): PETER JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

IV. Provider business mailing address

124 OCEAN AVE APT 307
SALEM MA
01970-2990
US

V. Phone/Fax

Practice location:
  • Phone: 617-267-0900
  • Fax:
Mailing address:
  • Phone: 508-317-1944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2354716
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2354716
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: