Healthcare Provider Details

I. General information

NPI: 1154953560
Provider Name (Legal Business Name): KIM N HULTS NGUYEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS ST STE 201
BRIGHTON MA
02135-3514
US

IV. Provider business mailing address

40 TRAVELER ST APT 204
BOSTON MA
02118-2980
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2442
  • Fax: 617-202-4349
Mailing address:
  • Phone: 857-294-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA7424
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7424
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: