Provider Demographics
NPI:1578897591
Name:LAU, JENIVI (PA-C)
Entity Type:Individual
Prefix:
First Name:JENIVI
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENIVI
Other - Middle Name:
Other - Last Name:MARUCUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:26732 CROWN VALLEY PKWY
Mailing Address - Street 2:#351
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26732 CROWN VALLEY PKWY
Practice Address - Street 2:#351
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6306
Practice Address - Country:US
Practice Address - Phone:949-364-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2293363A00000X
CA21199363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant