Provider Demographics
NPI:1093995011
Name:KROG, LAURA JEAN
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:KROG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 WEHRLE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7332
Mailing Address - Country:US
Mailing Address - Phone:716-632-3700
Mailing Address - Fax:716-632-5083
Practice Address - Street 1:2699 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7332
Practice Address - Country:US
Practice Address - Phone:716-632-3700
Practice Address - Fax:716-632-5083
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015813-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist