Healthcare Provider Details

I. General information

NPI: 1659450021
Provider Name (Legal Business Name): DONALD LAZURE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT STREET BLK 1570
BOSTON MA
02114
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2806
  • Fax:
Mailing address:
  • Phone: 617-724-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1644
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: