Provider Demographics
NPI:1699123398
Name:MEDEIROS, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MEDEIROS
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 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-516-4265
Mailing Address - Fax:
Practice Address - Street 1:19 OLD ROLLINSFORD RD
Practice Address - Street 2:BUILDING B
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2807
Practice Address - Country:US
Practice Address - Phone:603-516-4265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3105012Medicaid
NHT400327001Medicare PIN