Provider Demographics
NPI:1265849350
Name:MATJASICH, LAURA (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MATJASICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LONDONDERRY TURNKPIKE BYPASS 28
Mailing Address - Street 2:
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106
Mailing Address - Country:US
Mailing Address - Phone:603-314-5980
Mailing Address - Fax:
Practice Address - Street 1:27 LONDONDERRY TPKE
Practice Address - Street 2:
Practice Address - City:HOOKSETT
Practice Address - State:NH
Practice Address - Zip Code:03106-2012
Practice Address - Country:US
Practice Address - Phone:603-314-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5673235-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5673235-4405OtherNA