Provider Demographics
NPI:1316024490
Name:O'TOOLE, LAURIE (PA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:O'TOOLE
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 1:293 UPPER FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-2184
Mailing Address - Country:US
Mailing Address - Phone:585-922-0200
Mailing Address - Fax:
Practice Address - Street 1:293 UPPER FALLS BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-2184
Practice Address - Country:US
Practice Address - Phone:585-922-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03052848Medicaid
NYJ400006034Medicare PIN