Provider Demographics
NPI:1326120197
Name:PERRY, LAUREEN ANN (PA)
Entity Type:Individual
Prefix:
First Name:LAUREEN
Middle Name:ANN
Last Name:PERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREEN
Other - Middle Name:ANN
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPAC
Mailing Address - Street 1:454 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5532
Mailing Address - Country:US
Mailing Address - Phone:518-587-1141
Mailing Address - Fax:
Practice Address - Street 1:211 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866
Practice Address - Country:US
Practice Address - Phone:518-587-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02554992Medicaid
S73010Medicare UPIN
NY02554992Medicaid