Healthcare Provider Details

I. General information

NPI: 1033728084
Provider Name (Legal Business Name): JONATHAN ADRIAN MEN-KUNE YEUNG LAIWAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 02/12/2024
Certification Date: 11/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE # K3-B23
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-5864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number282950
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: