Provider Demographics
NPI:1598020109
Name:GREGORY, LAURA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:GREGORY
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 1:202 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-2426
Mailing Address - Country:US
Mailing Address - Phone:540-639-5188
Mailing Address - Fax:540-639-9215
Practice Address - Street 1:202 8TH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2426
Practice Address - Country:US
Practice Address - Phone:540-639-5188
Practice Address - Fax:540-639-9215
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003909363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical