Provider Demographics
NPI:1497806921
Name:RUMMEL, LAURA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:RUMMEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:KOTKOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2232 W VIA CAMILLE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2348
Mailing Address - Country:US
Mailing Address - Phone:805-709-3840
Mailing Address - Fax:
Practice Address - Street 1:11669 SANTA MONICA BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2929
Practice Address - Country:US
Practice Address - Phone:310-315-4989
Practice Address - Fax:310-998-3282
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ29519Medicare UPIN
WPA16527BMedicare PIN