Provider Demographics
NPI:1194831933
Name:LAN, LAUREL H (PA)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:H
Last Name:LAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:C
Other - Last Name:HILDERBRANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7500 IRON BAR LN
Mailing Address - Street 2:SUITE 215
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3603
Mailing Address - Country:US
Mailing Address - Phone:571-261-1234
Mailing Address - Fax:571-261-2235
Practice Address - Street 1:7500 IRON BAR LN
Practice Address - Street 2:SUITE 215
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3603
Practice Address - Country:US
Practice Address - Phone:571-261-1234
Practice Address - Fax:571-261-2235
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030409363A00000X
NY011914-1363A00000X
VA0110002978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant