Healthcare Provider Details

I. General information

NPI: 1013982677
Provider Name (Legal Business Name): LARA L BENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE - BCH 3129 BOSTON CHILDRENS HOSPITAL
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6460
  • Fax:
Mailing address:
  • Phone: 617-355-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1513
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: