Basic Information
| Provider Information | |||||||||
| NPI: | 1437170370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAROCQUE | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 SILAS DEANE HWY | ||||||||
| Address2: | HHC CVO ENROLLMENT 1ST FLOOR | ||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609726970 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 RANDOLPH RD | ||||||||
| Address2: | STE 900 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 00181 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 00181 | 01 | CT | CT LIC | OTHER |