Provider Demographics
NPI:1407426562
Name:WEST, LAUREL (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 608
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32041-0608
Mailing Address - Country:US
Mailing Address - Phone:904-643-0574
Mailing Address - Fax:912-427-9851
Practice Address - Street 1:790 VETERAN'S PARKWAY SUITE #101
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-427-8433
Practice Address - Fax:912-427-9851
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9280363A00000X
FLPA9111487363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant