Provider Demographics
NPI:1629470661
Name:OKOROFSKY, LAUREL
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:OKOROFSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 WILLIAMS HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5661
Mailing Address - Country:US
Mailing Address - Phone:541-474-6053
Mailing Address - Fax:541-474-4527
Practice Address - Street 1:1716 WILLIAMS HWY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5661
Practice Address - Country:US
Practice Address - Phone:541-474-6053
Practice Address - Fax:541-474-4527
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017939363AM0700X
ORPA187788363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty