Healthcare Provider Details

I. General information

NPI: 1538201710
Provider Name (Legal Business Name): PAUL LEBOEUF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

81 ELECTRIC ST
WORCESTER MA
01610-3022
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-6030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN110014
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: