Provider Demographics
NPI:1235192527
Name:MOYLAN, LAURA LOOMER (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LOOMER
Last Name:MOYLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3880
Mailing Address - Country:US
Mailing Address - Phone:540-772-6920
Mailing Address - Fax:
Practice Address - Street 1:1930 BRAEBURN DR
Practice Address - Street 2:SUITE B
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7391
Practice Address - Country:US
Practice Address - Phone:540-776-6800
Practice Address - Fax:540-776-2919
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-09
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54-1832336OtherTAX ID #
VA6209718Medicaid
VA282028OtherBCBS PROVIDER NUMBER
VAE91627Medicare UPIN
VA160001435Medicare ID - Type UnspecifiedMEDICARE PROVIDER #