Healthcare Provider Details

I. General information

NPI: 1336175066
Provider Name (Legal Business Name): IAN A LAROSE PCNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GOVE ST
EAST BOSTON MA
02128-1920
US

IV. Provider business mailing address

10 GOVE ST
EAST BOSTON MA
02128-1920
US

V. Phone/Fax

Practice location:
  • Phone: 617-569-5800
  • Fax: 617-568-4780
Mailing address:
  • Phone: 617-569-5800
  • Fax: 617-568-4780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number254990
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: