Basic Information
| Provider Information | |||||||||
| NPI: | 1609239144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUDEL | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DEVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 E NEWTON ST # C515 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388442 | ||||||||
| FaxNumber: | 6176388409 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 E NEWTON ST # C515 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388442 | ||||||||
| FaxNumber: | 6176388409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.