Provider Demographics
NPI:1275010407
Name:GRADWELL, LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GRADWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 WERTMAN RD
Mailing Address - Street 2:
Mailing Address - City:FOGELSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18051-2041
Mailing Address - Country:US
Mailing Address - Phone:484-264-2220
Mailing Address - Fax:
Practice Address - Street 1:1736 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5656
Practice Address - Country:US
Practice Address - Phone:610-628-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059914363A00000X
PAOA004533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant