Provider Demographics
NPI:1538520713
Name:GEOGHEGAN, JOHANNA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:GEOGHEGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 WASHINGTON ST
Mailing Address - Street 2:BLUE 201
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-965-4263
Mailing Address - Fax:
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:BLUE 201
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-965-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5630363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA5630OtherPHYSICIAN ASSISTANT LICENSE