Provider Demographics
NPI:1295373710
Name:TOBASCO, LAUREN N (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:N
Last Name:TOBASCO
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 1:1403 MEDICAL PLAZA DR STE 102
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1047
Mailing Address - Country:US
Mailing Address - Phone:407-321-4500
Mailing Address - Fax:
Practice Address - Street 1:1403 MEDICAL PLAZA DR STE 102
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1047
Practice Address - Country:US
Practice Address - Phone:407-321-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9116932363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295373710Medicaid