Basic Information
| Provider Information | |||||||||
| NPI: | 1104977354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COMEIRO | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024456007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8573070896 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 37 FRIEND ST | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019023068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817156633 | ||||||||
| FaxNumber: | 7812685070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN209156 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0375420 | 05 | MA | MEDICAID |