Healthcare Provider Details

I. General information

NPI: 1659845642
Provider Name (Legal Business Name): LAURA NEEDHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALBANY ST SHAPIRO 3 STE A
BOSTON MA
02118
US

IV. Provider business mailing address

720 HARRISON AVE # DOB503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9111636
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6888
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: