Provider Demographics
NPI:1083666457
Name:MURRAY, LAURIE R (PA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:R
Last Name:MURRAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:BARLAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:896 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3439
Mailing Address - Country:US
Mailing Address - Phone:937-433-6513
Mailing Address - Fax:937-291-3398
Practice Address - Street 1:896 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3439
Practice Address - Country:US
Practice Address - Phone:937-433-6513
Practice Address - Fax:937-291-3398
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH108425OtherMEDICARE PTAN
OH0074307Medicaid
OH0074307Medicaid
OHH108420OtherMEDICARE PTAN