Provider Demographics
NPI:1053324624
Name:PENNAVARIA, LAURA KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:KAY
Last Name:PENNAVARIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 NE SAVANNAH DR STE 1
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4866
Mailing Address - Country:US
Mailing Address - Phone:541-516-1705
Mailing Address - Fax:541-833-2619
Practice Address - Street 1:568 NE SAVANNAH DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4866
Practice Address - Country:US
Practice Address - Phone:541-516-1705
Practice Address - Fax:541-833-2619
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82578207Q00000X
ORMD156899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD156899OtherSTATE MEDICAL LICENSE
ORMD156899OtherSTATE MEDICAL LICENSE
BR8250831OtherDEA
I19865Medicare UPIN