Healthcare Provider Details

I. General information

NPI: 1972584100
Provider Name (Legal Business Name): ELIZABETH LANE ALQUEZA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 FRANCIS ST SUITE 8E
BOSTON MA
02215-5501
US

IV. Provider business mailing address

33 KENDALL ST UNIT #1
BROOKLINE MA
02445-7566
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-9716
  • Fax: 617-632-1065
Mailing address:
  • Phone: 617-632-9716
  • Fax: 617-632-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9102831
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2112
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: