Healthcare Provider Details

I. General information

NPI: 1518662147
Provider Name (Legal Business Name): MATTHEW JOSEPH LAVALLEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WHITE 1
BOSTON MA
02114-2696
US

IV. Provider business mailing address

12 BALDWIN RD
WESTFORD MA
01886-2066
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4100
  • Fax: 617-726-7415
Mailing address:
  • Phone: 978-799-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA100060
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: