Healthcare Provider Details

I. General information

NPI: 1740740430
Provider Name (Legal Business Name): REBECCA DARBY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 HARRISON AVE RADIOLOGY - BOSTON MEDICAL CENTER
BOSTON MA
02118-2905
US

IV. Provider business mailing address

720 HARRISON AVENUE ENROLLMENT OFFICE DOB 503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6610
  • Fax: 617-638-6616
Mailing address:
  • Phone: 617-414-5405
  • Fax: 617-414-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6994
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: