Provider Demographics
NPI:1760145643
Name:BUKHOVKO, LARISA VLADIMIROVNA (NP)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:VLADIMIROVNA
Last Name:BUKHOVKO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BROADMOOR LN
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-4951
Mailing Address - Country:US
Mailing Address - Phone:978-818-5705
Mailing Address - Fax:
Practice Address - Street 1:20 LINDEN ST
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1711
Practice Address - Country:US
Practice Address - Phone:617-782-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAG10210012363L00000X
MARN2290340363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner