Basic Information
| Provider Information | |||||||||
| NPI: | 1912962218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAIR | ||||||||
| FirstName: | PREMILA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 532 SUMNER AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011082458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
| FaxNumber: | 4137371643 | ||||||||
| Practice Location | |||||||||
| Address1: | 532 SUMNER AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011082458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
| FaxNumber: | 4137371643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 190033 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1310097 | 05 | MA | MEDICAID | MN0708935 | 01 | MA | DEA NUMBER | OTHER | 0037112 | 01 | MA | PROVIDER NHP NUMBER | OTHER | MN0564876 I | 01 | MA | CSR NUMBER | OTHER | 83-02800 | 01 | MA | PROVIDER EVERCARE NUMBER | OTHER |