Healthcare Provider Details

I. General information

NPI: 1942063243
Provider Name (Legal Business Name): JUNCHU HAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/31/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 MAIN ST
WALTHAM MA
02451-0602
US

IV. Provider business mailing address

675 MAIN ST
WALTHAM MA
02451-0602
US

V. Phone/Fax

Practice location:
  • Phone: 812-606-9019
  • Fax:
Mailing address:
  • Phone: 812-606-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: