Provider Demographics
NPI:1619980976
Name:DELORME, LAUREL ANNE (PA)
Entity Type:Individual
Prefix:MISS
First Name:LAUREL
Middle Name:ANNE
Last Name:DELORME
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 248
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-0248
Mailing Address - Country:US
Mailing Address - Phone:716-699-9032
Mailing Address - Fax:716-699-9035
Practice Address - Street 1:8003 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9528
Practice Address - Country:US
Practice Address - Phone:315-288-4006
Practice Address - Fax:315-288-4760
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03448762Medicaid
NYJ400086460Medicare PIN
NYJ400068358Medicare PIN
NYJ400086459Medicare PIN