Provider Demographics
NPI:1225642580
Name:PATRICK, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PATRICK
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 1:4 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-9777
Mailing Address - Country:US
Mailing Address - Phone:518-935-0443
Mailing Address - Fax:
Practice Address - Street 1:4 COUNTRY LN
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-9777
Practice Address - Country:US
Practice Address - Phone:518-935-0443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025210-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant