Provider Demographics
NPI:1730910811
Name:MUKASA, FAUZI
Entity type:Individual
Prefix:
First Name:FAUZI
Middle Name:
Last Name:MUKASA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1237
Mailing Address - Country:US
Mailing Address - Phone:857-417-7893
Mailing Address - Fax:
Practice Address - Street 1:44 WINTER ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1237
Practice Address - Country:US
Practice Address - Phone:857-417-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN953152164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse