Healthcare Provider Details

I. General information

NPI: 1265402549
Provider Name (Legal Business Name): LAURIE HELEN BONCI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE HELEN BOURGELAS

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 FOREST ST
NEWTON HIGHLANDS MA
02461-1445
US

IV. Provider business mailing address

31 FOREST ST
NEWTON HIGHLANDS MA
02461-1445
US

V. Phone/Fax

Practice location:
  • Phone: 617-916-1300
  • Fax: 617-916-1300
Mailing address:
  • Phone: 617-916-1300
  • Fax: 617-916-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number928
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105275
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: