Provider Demographics
NPI:1578194247
Name:KETELSEN, LAURA PAVEL (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:PAVEL
Last Name:KETELSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SHENANDOAH BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2022
Mailing Address - Country:US
Mailing Address - Phone:703-314-4055
Mailing Address - Fax:
Practice Address - Street 1:5316 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2591
Practice Address - Country:US
Practice Address - Phone:833-660-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL128906367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered