Healthcare Provider Details

I. General information

NPI: 1265403794
Provider Name (Legal Business Name): BRUCE LASTRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 PAGE HILL RD
BERLIN NH
03570-3531
US

IV. Provider business mailing address

59 PAGE HILL RD
BERLIN NH
03570-3531
US

V. Phone/Fax

Practice location:
  • Phone: 603-752-2300
  • Fax: 603-326-5831
Mailing address:
  • Phone: 603-752-2200
  • Fax: 603-326-5831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1625
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: