Basic Information
Provider Information | |||||||||
NPI: | 1558648949 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERRON | ||||||||
FirstName: | ALYSSA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CROWELL | ||||||||
OtherFirstName: | ALYSSA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 19 FARRINGTON CORNER RD | ||||||||
Address2: |   | ||||||||
City: | HOPKINTON | ||||||||
State: | NH | ||||||||
PostalCode: | 032292020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032287575 | ||||||||
FaxNumber: | 6032287585 | ||||||||
Practice Location | |||||||||
Address1: | 19 FARRINGTON CORNER RD | ||||||||
Address2: |   | ||||||||
City: | HOPKINTON | ||||||||
State: | NH | ||||||||
PostalCode: | 032292020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032287575 | ||||||||
FaxNumber: | 6032287585 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2011 | ||||||||
LastUpdateDate: | 11/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-05126 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 0860 | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 0103674 | 05 | OH |   | MEDICAID | 1558648949 | 05 | NC |   | MEDICAID |