Healthcare Provider Details

I. General information

NPI: 1639810807
Provider Name (Legal Business Name): MARY PARKER JOHNSTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1099
US

IV. Provider business mailing address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1099
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-1000
  • Fax:
Mailing address:
  • Phone: 617-665-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9335
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4930
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: