Provider Demographics
NPI:1871099861
Name:CHANG, KATHERINE (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WOODLAND RD STE 213
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1711
Mailing Address - Country:US
Mailing Address - Phone:781-662-7990
Mailing Address - Fax:
Practice Address - Street 1:3 WOODLAND RD STE 213
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1711
Practice Address - Country:US
Practice Address - Phone:781-662-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2376646363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR59866587OtherBLUE CROSS BLUE SHIELD