Provider Demographics
NPI:1437171238
Name:SPORL, LAURA G (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:SPORL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 49TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-2421
Mailing Address - Country:US
Mailing Address - Phone:253-459-7699
Mailing Address - Fax:253-459-7675
Practice Address - Street 1:4215 49TH AVE NE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98422-2421
Practice Address - Country:US
Practice Address - Phone:253-459-7699
Practice Address - Fax:253-459-7675
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10073R207RC0000X
WAMD00047209207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3374SPOtherBLUE SHIELD VM
LA1686450Medicaid
WA5812274OtherAETNA SPECIALIST PIN VM
WA8481152Medicaid
WAP00394683OtherRAILROAD MC # VM
WA8481152Medicaid
WA5812274OtherAETNA SPECIALIST PIN VM