Healthcare Provider Details

I. General information

NPI: 1548736648
Provider Name (Legal Business Name): VYACHESLAV VERBETSKY NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STAFFORD ST STE 101
SPRINGFIELD MA
01104-3581
US

IV. Provider business mailing address

300 STAFFORD ST STE 101
SPRINGFIELD MA
01104-3581
US

V. Phone/Fax

Practice location:
  • Phone: 413-732-1928
  • Fax: 413-733-5604
Mailing address:
  • Phone: 413-748-7076
  • Fax: 413-732-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2279149
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: