Provider Demographics
NPI:1174017024
Name:ANDERSON, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:MENKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:802-909-2053
Mailing Address - Fax:
Practice Address - Street 1:23 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2520
Practice Address - Country:US
Practice Address - Phone:603-942-2171
Practice Address - Fax:603-371-3104
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1303OtherNH LICENSE