Provider Demographics
NPI:1457316762
Name:HERBST, LAURIE M (RPA-C)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:M
Last Name:HERBST
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:M
Other - Last Name:COSTLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:ELM AND CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263-0001
Mailing Address - Country:US
Mailing Address - Phone:716-845-2300
Mailing Address - Fax:716-845-3423
Practice Address - Street 1:ELM AND CARLTON STREETS
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:716-845-3423
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01718083Medicaid
NYS32182Medicare UPIN