Provider Demographics
NPI:1104977354
Name:COMEIRO, KENNETH J JR (NP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:COMEIRO
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6007
Mailing Address - Country:US
Mailing Address - Phone:857-307-0896
Mailing Address - Fax:
Practice Address - Street 1:37 FRIEND ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-3068
Practice Address - Country:US
Practice Address - Phone:781-715-6633
Practice Address - Fax:781-268-5070
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN209156363L00000X
MA209156363LA2200X, 363LG0600X, 364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0375420Medicaid
MANP30371Medicare PIN
MA0375420Medicaid
MANP303701Medicare PIN