Provider Demographics
NPI:1003867656
Name:LAURINAITIS, INGRID (PA-C)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:
Last Name:LAURINAITIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 13TH AVE S
Mailing Address - Street 2:SUITE 170A
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3233
Mailing Address - Country:US
Mailing Address - Phone:904-249-4456
Mailing Address - Fax:904-249-7703
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:SUITE 170A
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-249-4456
Practice Address - Fax:904-249-7703
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9107329363AM0700X
MI5601004336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical