Provider Demographics
NPI:1164959565
Name:BERRY, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 PLAZA DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR STE 1100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4169
Practice Address - Country:US
Practice Address - Phone:715-847-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant