Healthcare Provider Details

I. General information

NPI: 1912548702
Provider Name (Legal Business Name): KEARA LAURA MARTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 GREEN ST STE 109
GARDNER MA
01440-1377
US

IV. Provider business mailing address

250 GREEN ST STE 109
GARDNER MA
01440-1377
US

V. Phone/Fax

Practice location:
  • Phone: 978-630-6545
  • Fax:
Mailing address:
  • Phone: 978-630-6545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: