Provider Demographics
NPI:1518662147
Name:LAVALLEE, MATTHEW JOSEPH
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:LAVALLEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-2066
Mailing Address - Country:US
Mailing Address - Phone:978-799-1281
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WHITE 1
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-4100
Practice Address - Fax:617-726-7415
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA100060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant