Basic Information
| Provider Information | |||||||||
| NPI: | 1801982541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANTZ | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | LAHEY CLINIC | ||||||||
| Address2: | 41 MALL ROAD | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817445100 | ||||||||
| FaxNumber: | 7817445215 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 CABOT ST | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019152511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789271919 | ||||||||
| FaxNumber: | 9789276102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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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 | 363L00000X | 161983 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0383520 | 05 | MA | MEDICAID |