Provider Demographics
NPI:1275588063
Name:FASHAKIN, LAURIE (PA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:FASHAKIN
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 1:515 W SR 434
Mailing Address - Street 2:STE 210
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4981
Mailing Address - Country:US
Mailing Address - Phone:407-332-8080
Mailing Address - Fax:407-260-0602
Practice Address - Street 1:800 N MAITLAND AVE STE 202
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4499
Practice Address - Country:US
Practice Address - Phone:407-389-2020
Practice Address - Fax:407-389-2021
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3630CMedicare ID - Type Unspecified
FLQ26396Medicare UPIN