Healthcare Provider Details

I. General information

NPI: 1972059665
Provider Name (Legal Business Name): PETERSON REMY FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WINDSOR ST
CAMBRIDGE MA
02139-3647
US

IV. Provider business mailing address

119 WINDSOR ST
CAMBRIDGE MA
02139-3647
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-3600
  • Fax: 617-665-3603
Mailing address:
  • Phone: 617-665-3600
  • Fax: 617-665-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2281249
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: