Provider Demographics
NPI:1184833212
Name:KOO, LAURA WARNOCK (CRNP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:WARNOCK
Last Name:KOO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:HELEN
Other - Last Name:WARNOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:830 W 40TH ST
Mailing Address - Street 2:ROLAND PARK PLACE AMBULATORY CARE CLINIC
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2116
Mailing Address - Country:US
Mailing Address - Phone:410-243-7284
Mailing Address - Fax:410-243-5804
Practice Address - Street 1:830 W 40TH ST
Practice Address - Street 2:ROLAND PARK PLACE AMBULATORY CARE CLINIC
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2116
Practice Address - Country:US
Practice Address - Phone:410-243-7284
Practice Address - Fax:410-243-5804
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR126745363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP12359Medicare UPIN