Provider Demographics
NPI:1508305541
Name:MEDANIC, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MEDANIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-2186
Mailing Address - Country:US
Mailing Address - Phone:641-682-7511
Mailing Address - Fax:641-684-3199
Practice Address - Street 1:1013 PENNSYLVANIA AVE # A-C
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2110
Practice Address - Country:US
Practice Address - Phone:641-683-6868
Practice Address - Fax:641-683-6869
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28212530A363LF0000X
IAA149465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily