Provider Demographics
NPI:1891482857
Name:ALFATAFTA, WASAN GHASSAN
Entity type:Individual
Prefix:
First Name:WASAN
Middle Name:GHASSAN
Last Name:ALFATAFTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAYYAN
Other - Middle Name:
Other - Last Name:ALFATAFTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1493 CAMBRIDGE ST RM 239
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1099
Mailing Address - Country:US
Mailing Address - Phone:617-575-5399
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1099
Practice Address - Country:US
Practice Address - Phone:617-665-1068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program