MEDICARE: BRYAN LAVOIE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	0010-04512	NC
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1225468119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN LAVOIE

Provider Business Mailing Address
First Line	:	2032 S 17TH ST
Second Line	:	SUITE 101
City	:	WILMINGTON
State	:	NC
Zip	:	28401-6677
Country	:	US
Telephone Number	:	910-763-3738
Fax Number	:	910-763-0454

Provider Business Practice Location Address
First Line	:	2032 S 17TH ST
Second Line	:	SUITE 101
City	:	WILMINGTON
State	:	NC
Zip	:	28401-6677
Country	:	US
Telephone Number	:	910-763-3738
Fax Number	:	910-763-0454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	04/27/2017

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Directions to “ BRYAN LAVOIE ” Practice Location

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