Basic Information
| Provider Information | |||||||||
| NPI: | 1912129917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLEY CYR | ||||||||
| FirstName: | MARYELLEN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CYR | ||||||||
| OtherFirstName: | MARYELLEN | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 77 MASS AVE E 23-230 | ||||||||
| Address2: | MIT MEDICAL | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172534431 | ||||||||
| FaxNumber: | 6173554085 | ||||||||
| Practice Location | |||||||||
| Address1: | 287 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | ALLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021341010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177830500 | ||||||||
| FaxNumber: | 6177835514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 08/25/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 122618 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.