Provider Demographics
NPI:1770558009
Name:LAVALLEE, PAUL J (NP)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:J
Last Name:LAVALLEE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-2593
Practice Address - Fax:774-443-7066
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN212006363L00000X
MA212006363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110013288AMedicaid
MA0314293Medicaid
MAUX0079Medicare PIN