Basic Information
| Provider Information | |||||||||
| NPI: | 1881834174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETWILER | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | BRASSARD | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 WEBSTER ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023391227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817546545 | ||||||||
| FaxNumber: | 7815360016 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 WEBSTER ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023391227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817546545 | ||||||||
| FaxNumber: | 7815360016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2009 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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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 | 363LF0000X | 268698 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 110091419A | 05 | MA | MEDICAID |