Healthcare Provider Details

I. General information

NPI: 1417040577
Provider Name (Legal Business Name): PETER JAY FLOOD PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

1A OCEANSIDE DR
SCITUATE MA
02066-2916
US

V. Phone/Fax

Practice location:
  • Phone: 508-583-4500
  • Fax: 774-826-2585
Mailing address:
  • Phone: 781-544-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number835
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: