Provider Demographics
NPI:1255316907
Name:DERMENJIAN, LAURA ERIKA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ERIKA
Last Name:DERMENJIAN
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 1:1950 LAUREL MANOR DR
Mailing Address - Street 2:STE 224
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5603
Mailing Address - Country:US
Mailing Address - Phone:352-751-6565
Mailing Address - Fax:352-205-7777
Practice Address - Street 1:1950 LAUREL MANOR DR
Practice Address - Street 2:STE 224
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162
Practice Address - Country:US
Practice Address - Phone:352-751-6565
Practice Address - Fax:352-205-7777
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101262363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290911100Medicaid
FLK2260Medicare UPIN
FL290911100Medicaid
FLE4524ZMedicare Oscar/Certification