Basic Information
| Provider Information | |||||||||
| NPI: | 1184725038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGAL | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | MEDFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020523120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087281905 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN153493 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | S400469060 | 01 | MA | MEDICARE | OTHER | 110020132A | 05 | MA | MEDICAID |