Provider Demographics
NPI:1669840310
Name:MCCUTCHEON, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MCCUTCHEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:MCINERNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:538 N PASEO DE ONATE
Mailing Address - Street 2:PO BOX 158
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2618
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:15136 STATE ROAD 75
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:575-587-2205
Practice Address - Fax:575-587-1944
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical