Healthcare Provider Details

I. General information

NPI: 1336697382
Provider Name (Legal Business Name): SAMUEL ROBERT LAJOIE MS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 HARRISON AVENUE MOAKLEY, SUITE 3500
BOSTON MA
02118
US

IV. Provider business mailing address

720 HARRISON AVE DOB 503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-8054
  • Fax: 617-414-8055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6021
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: