Healthcare Provider Details

I. General information

NPI: 1821230442
Provider Name (Legal Business Name): LAURA M YACOVONE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE LO-367
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE LO-367
BOSTON MA
02115-5724
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3748
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: