Provider Demographics
NPI:1629328455
Name:MAIORANA, LAURA KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHLEEN
Last Name:MAIORANA
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 1:3050 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3819
Mailing Address - Country:US
Mailing Address - Phone:810-385-4441
Mailing Address - Fax:810-385-1540
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-989-3300
Practice Address - Fax:810-985-2671
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629328455Medicaid