Healthcare Provider Details

I. General information

NPI: 1114665429
Provider Name (Legal Business Name): ANDREW SIMON BAYLOUNY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

62 13TH ST
CHARLESTOWN MA
02129-2056
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2784
  • Fax:
Mailing address:
  • Phone: 617-724-4133
  • Fax: 617-643-7941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9255
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: