Healthcare Provider Details

I. General information

NPI: 1477260701
Provider Name (Legal Business Name): PIETER R REPPENHAGEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PELHAM RD STE 1
SALEM NH
03079-3077
US

IV. Provider business mailing address

575 TURNPIKE ST STE 11
NORTH ANDOVER MA
01845-5937
US

V. Phone/Fax

Practice location:
  • Phone: 978-794-1946
  • Fax:
Mailing address:
  • Phone: 978-794-1946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2075
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: