Healthcare Provider Details

I. General information

NPI: 1619931813
Provider Name (Legal Business Name): NICOLE DETTMANN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

147 MILK ST PROVIDER ENROLLMENT - 9TH FLOOR
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1000
  • Fax: 617-421-6084
Mailing address:
  • Phone: 617-559-8053
  • Fax: 617-421-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1603
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1603
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: