Healthcare Provider Details

I. General information

NPI: 1780054411
Provider Name (Legal Business Name): JONATHAN COVENEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WHITE 1
BOSTON MA
02114-2621
US

IV. Provider business mailing address

22 NOWELL RD
MELROSE MA
02176-1217
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4100
  • Fax: 617-726-7415
Mailing address:
  • Phone: 781-307-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA5540
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: