Provider Demographics
NPI:1265402549
Name:BONCI, LAURIE HELEN (PA-C)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:HELEN
Last Name:BONCI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:HELEN
Other - Last Name:BOURGELAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON HIGHLANDS
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1445
Mailing Address - Country:US
Mailing Address - Phone:617-916-1300
Mailing Address - Fax:617-916-1300
Practice Address - Street 1:31 FOREST ST
Practice Address - Street 2:
Practice Address - City:NEWTON HIGHLANDS
Practice Address - State:MA
Practice Address - Zip Code:02461-1445
Practice Address - Country:US
Practice Address - Phone:617-916-1300
Practice Address - Fax:617-916-1300
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA928363A00000X
FLPA9105275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000051543OtherBMC HEALTHNET
MA000928OtherCONNECTICARE
MA1265402549OtherFALLON CHP
MA83-08485OtherEVERCARE
S65375Medicare UPIN
FLGO593ZMedicare PIN
MA000928OtherCONNECTICARE