Provider Demographics
NPI:1568768562
Name:MINUTOLO, LAURA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:MINUTOLO
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 1:172 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3214
Mailing Address - Country:US
Mailing Address - Phone:631-338-5439
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant