Provider Demographics
NPI:1619913795
Name:BROWN, LAURA TODD (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:TODD
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12247
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110
Mailing Address - Country:US
Mailing Address - Phone:817-737-6585
Mailing Address - Fax:
Practice Address - Street 1:2751 GREEN OAKS ROAD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116
Practice Address - Country:US
Practice Address - Phone:817-737-6552
Practice Address - Fax:817-732-6597
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S74783Medicare UPIN
TX00290WMedicare ID - Type UnspecifiedGROUP
TX8B5122Medicare ID - Type UnspecifiedINDIVIDUAL