Basic Information
Provider Information | |||||||||
NPI: | 1477978013 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LACASSE | ||||||||
FirstName: | BETHANY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THIBODEAU | ||||||||
OtherFirstName: | BETHANY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 280 CHESTNUT ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011991619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137945700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 759 CHESTNUT ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011991619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137948120 | ||||||||
FaxNumber: | 4137941767 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2014 | ||||||||
LastUpdateDate: | 02/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.