Healthcare Provider Details

I. General information

NPI: 1104471416
Provider Name (Legal Business Name): JERMAINE DARIO OKANG THOMAS AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2019
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MASSACHUSETTS AVE 2ND FL
BOSTON MA
02118-0211
US

IV. Provider business mailing address

801 ALBANY ST FL GROUND
BOSTON MA
02119-2560
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-7399
  • Fax: 617-414-4676
Mailing address:
  • Phone: 617-414-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN2320575
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN2320575
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN2320575
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: