Provider Demographics
NPI:1679854798
Name:LACASSE, TARYN PERSIA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TARYN
Middle Name:PERSIA
Last Name:LACASSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARYN
Other - Middle Name:BRIN
Other - Last Name:PERSIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:617-726-3884
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-742-8787
Practice Address - Fax:603-740-2446
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4224363AM0700X
NH1875363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110121445AMedicaid