Provider Demographics
NPI:1861632143
Name:WILLARD, LAURA MINNETTE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MINNETTE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-421-1000
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06751363AM0700X
CAPA20233363AM0700X
MAPA4709363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical