Provider Demographics
NPI:1598926214
Name:HEARST, LAURA J (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:HEARST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:MAMCHUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-4562
Mailing Address - Fax:207-662-6236
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-4562
Practice Address - Fax:207-662-6236
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSRA-100001367500000X
CO125032367500000X
MERNA83441367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32408552Medicaid
COP00860353OtherRR MEDICARE
ME000750201Medicare PIN
COP00860353OtherRR MEDICARE
ME000750202Medicare PIN