Provider Demographics
NPI:1659485753
Name:STAPLETON, LAURA LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:STAPLETON
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 1:85 POHEGANUT DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3216
Mailing Address - Country:US
Mailing Address - Phone:860-448-6303
Mailing Address - Fax:860-448-9678
Practice Address - Street 1:85 POHEGANUT DR
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3216
Practice Address - Country:US
Practice Address - Phone:860-448-6303
Practice Address - Fax:860-448-9678
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P62540Medicare UPIN