Provider Demographics
NPI:1902186158
Name:JAFFE, DAVID (NP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JAFFE
Suffix:
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:PO BOX 3262
Mailing Address - Street 2:
Mailing Address - City:WAQUOIT
Mailing Address - State:MA
Mailing Address - Zip Code:02536-3262
Mailing Address - Country:US
Mailing Address - Phone:617-957-8063
Mailing Address - Fax:774-237-2510
Practice Address - Street 1:446 WAQUOIT HWY
Practice Address - Street 2:
Practice Address - City:WAQUOIT
Practice Address - State:MA
Practice Address - Zip Code:02536-5522
Practice Address - Country:US
Practice Address - Phone:774-255-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267688363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400258404Medicare UPIN