Provider Demographics
NPI:1477539138
Name:GIACOLETTO, LAURIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:GIACOLETTO
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 1:1250 S CLEARVIEW AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:407 N LINDSAY RD STE 103-104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-7710
Practice Address - Country:US
Practice Address - Phone:480-807-0084
Practice Address - Fax:480-807-0091
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9289363A00000X
AZ5413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z162194OtherMEDICARE PTAN
AZ859739Medicaid