Provider Demographics
NPI:1306377130
Name:MIKRUT, LAURI
Entity Type:Individual
Prefix:
First Name:LAURI
Middle Name:
Last Name:MIKRUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 SLATE CREEK DR
Mailing Address - Street 2:12
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14227-2862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 SLATE CREEK DR
Practice Address - Street 2:12
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14227-2862
Practice Address - Country:US
Practice Address - Phone:716-473-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY631262364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY631262OtherNYS