Provider Demographics
NPI:1083704829
Name:LAROCHELLE, LYNN BUJNEVICIE (PAC)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:BUJNEVICIE
Last Name:LAROCHELLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:LAROCHELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:300 STAFFORD ST
Mailing Address - Street 2:#154
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-4110
Mailing Address - Country:US
Mailing Address - Phone:413-781-5735
Mailing Address - Fax:
Practice Address - Street 1:300 STAFFORD ST
Practice Address - Street 2:#154
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-4110
Practice Address - Country:US
Practice Address - Phone:413-781-5735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1379363AS0400X
CT001164363AM0700X
MA1379363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1379OtherLICENSE
MAAP2104Medicare PIN