Provider Demographics
NPI:1306020912
Name:LAURA JACIMORE, PA
Entity Type:Organization
Organization Name:LAURA JACIMORE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:JACIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-971-4976
Mailing Address - Street 1:105 MONABREEZE WAY
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4369
Mailing Address - Country:US
Mailing Address - Phone:919-773-3735
Mailing Address - Fax:
Practice Address - Street 1:2450 CURTIS ELLIS DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2237
Practice Address - Country:US
Practice Address - Phone:252-443-8947
Practice Address - Fax:252-451-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891358HMedicaid
NC2021609BMedicare PIN
NCG21511Medicare UPIN