Provider Demographics
NPI:1346622594
Name:REED, LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:REED
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:RISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2154
Mailing Address - Country:US
Mailing Address - Phone:423-784-8492
Mailing Address - Fax:423-784-8358
Practice Address - Street 1:402 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1238
Practice Address - Country:US
Practice Address - Phone:606-549-2656
Practice Address - Fax:606-549-2855
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3573363A00000X
KY2301363A00000X
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3573OtherSTATE LICENSE
KY2301OtherSTATE LICENSE
TNQ038194Medicaid
KY7100469080Medicaid