Healthcare Provider Details

I. General information

NPI: 1205590890
Provider Name (Legal Business Name): DAVID RUNYAN FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-2818
  • Fax: 774-441-7799
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2357052
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2357052
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP877912
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: