Healthcare Provider Details

I. General information

NPI: 1104519099
Provider Name (Legal Business Name): AINSLEY WOBBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AINSLEY PITTMAN

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WHITE 1
BOSTON MA
02114
US

IV. Provider business mailing address

55 FRUIT ST WHITE 1
BOSTON MA
02114
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-7415
  • Fax:
Mailing address:
  • Phone: 617-726-7415
  • Fax: 617-726-7415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9370
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: