Provider Demographics
NPI:1366637183
Name:MCDONALD, LAURA M (APRN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3569 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1757
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:707-303-3611
Practice Address - Street 1:3883 AIRWAY DR STE 202
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1671
Practice Address - Country:US
Practice Address - Phone:707-303-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003676363LF0000X
CA20461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680365296OtherPROVIDER TAX ID
CT004236346Medicaid