Provider Demographics
NPI:1528041696
Name:HORN, LAURA C (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:C
Last Name:HORN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 PIPER HILL DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1690
Mailing Address - Country:US
Mailing Address - Phone:636-441-3444
Mailing Address - Fax:636-926-2858
Practice Address - Street 1:112 PIPER HILL DR
Practice Address - Street 2:SUITE 9
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1690
Practice Address - Country:US
Practice Address - Phone:636-441-3444
Practice Address - Fax:636-926-2858
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
MO2002028066207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00657543OtherRR MEDICARE
MO000097173Medicare ID - Type Unspecified
MO156580038Medicare PIN
Q05181Medicare UPIN