Basic Information
| Provider Information | |||||||||
| NPI: | 1437550027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEVCHENKO | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176323352 | ||||||||
| FaxNumber: | 6172786965 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176323352 | ||||||||
| FaxNumber: | 6172786965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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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 | 363A00000X | PA6194 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 110128835A | 05 | MA | MEDICAID |