Provider Demographics
NPI:1003876434
Name:WAVRA, LAURA L (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:WAVRA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAGAMORE PKWY W
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1569
Mailing Address - Country:US
Mailing Address - Phone:765-463-6722
Mailing Address - Fax:765-463-0905
Practice Address - Street 1:124 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1569
Practice Address - Country:US
Practice Address - Phone:765-463-6722
Practice Address - Fax:765-463-0905
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001832A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200506050Medicaid
INQ36746Medicare UPIN
IN815150YMedicare ID - Type Unspecified