Healthcare Provider Details

I. General information

NPI: 1629099270
Provider Name (Legal Business Name): STEPHEN LAROSE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WESTBORO STATE HOSPITAL 288 LYMAN ST
WESTBORO MA
01581-0288
US

IV. Provider business mailing address

WESTBORO STATE HOSPITAL 288 LYMAN ST
WESTBORO MA
01581-0288
US

V. Phone/Fax

Practice location:
  • Phone: 508-616-2339
  • Fax:
Mailing address:
  • Phone: 508-616-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number864
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: