Basic Information
| Provider Information | |||||||||
| NPI: | 1649207507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAX | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | SHAKER | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085596699 | ||||||||
| FaxNumber: | 5085834649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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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 | 176B00000X | 124599 | MA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | CN0308 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 0036811 | 01 | NEIGHBORHOOD HEALTH PLAN | OTHER |