=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245058775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEFFREY GAETAN LAPORTE MD , PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3155 LAKE WORTH RD
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-6917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-858-8817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 SEA PINES WAY
-----------------------------------------------------
City | LANTANA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33462-4248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-312-0938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 1871-PA
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10345
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------