Healthcare Provider Details

I. General information

NPI: 1508107806
Provider Name (Legal Business Name): ARY-LEX AUGUSTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 GEORGETOWNE DR
HYDE PARK MA
02136-1023
US

IV. Provider business mailing address

494 GEORGETOWNE DR
HYDE PARK MA
02136-1023
US

V. Phone/Fax

Practice location:
  • Phone: 754-234-3963
  • Fax:
Mailing address:
  • Phone: 754-234-3963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2290946
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: