Provider Demographics
NPI:1265462329
Name:HYSA, LAURESHA (MD)
Entity Type:Individual
Prefix:
First Name:LAURESHA
Middle Name:
Last Name:HYSA
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 1:5851 HOLMBERG RD
Mailing Address - Street 2:APT 2314
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4536
Mailing Address - Country:US
Mailing Address - Phone:954-775-0349
Mailing Address - Fax:
Practice Address - Street 1:8903 GLADES RD # SUITEK1A
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-4074
Practice Address - Country:US
Practice Address - Phone:561-955-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087399207R00000X
FLME112127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine