Healthcare Provider Details

I. General information

NPI: 1083704829
Provider Name (Legal Business Name): LYNN BUJNEVICIE LAROCHELLE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN LAROCHELLE PAC

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STAFFORD ST #154
SPRINGFIELD MA
01104-4110
US

IV. Provider business mailing address

300 STAFFORD ST #154
SPRINGFIELD MA
01104-4110
US

V. Phone/Fax

Practice location:
  • Phone: 413-781-5735
  • Fax:
Mailing address:
  • Phone: 413-781-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1379
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001164
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1379
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: