Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST CONNELL PAVILLION
BRIGHTON MA
02135
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2666
  • Fax:
Mailing address:
  • Phone: 617-414-5405
  • 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: