Provider Demographics
NPI:1285890392
Name:WISDOM, DOROTHY A (NP)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:A
Last Name:WISDOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:ANNE
Other - Last Name:MEDEIROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVENUE
Practice Address - Street 2:MOAKLEY, 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-6428
Practice Address - Fax:617-638-5756
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN252656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110084053AMedicaid
MA110084053AMedicaid