Basic Information
| Provider Information | |||||||||
| NPI: | 1528460326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNOX | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | DEANE | ||||||||
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| OtherLastName: | KNOX | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | DEANE | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 12TH FL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685532 | ||||||||
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| Practice Location | |||||||||
| Address1: | 460 SOUTHBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015012442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7742215135 | ||||||||
| FaxNumber: | 7742215136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 11/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0004105 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA5532 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 49203746 | 05 | CO | MEDICAID |