Provider Demographics
NPI:1417328253
Name:DESANCTIS, LAURA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:DESANCTIS
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 1:2367 ALDERMAN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1170
Mailing Address - Country:US
Mailing Address - Phone:727-403-2442
Mailing Address - Fax:
Practice Address - Street 1:15255 MAX LEGGETT PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7273
Practice Address - Country:US
Practice Address - Phone:904-244-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5150363A00000X
FLPA9109119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003172244AMedicaid
FL016102500Medicaid
FLIK640ZMedicare PIN