Basic Information
Provider Information | |||||||||
NPI: | 1902268469 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOYDSTUN | ||||||||
FirstName: | NATASHA | ||||||||
MiddleName: | VICTORIA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLACK | ||||||||
OtherFirstName: | NATASHA | ||||||||
OtherMiddleName: | VICTORIA | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 180 BERRY ST | ||||||||
Address2: |   | ||||||||
City: | NORTH ANDOVER | ||||||||
State: | MA | ||||||||
PostalCode: | 018455707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8586994428 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25 HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | NEWBURYPORT | ||||||||
State: | MA | ||||||||
PostalCode: | 019503867 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9784631000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2016 | ||||||||
LastUpdateDate: | 02/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207P00000X | 34.014119 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.