Provider Demographics
NPI:1679764633
Name:BRAKE, LAURA D (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:BRAKE
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:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:LEDERACH
Mailing Address - State:PA
Mailing Address - Zip Code:19450-0425
Mailing Address - Country:US
Mailing Address - Phone:800-528-0006
Mailing Address - Fax:732-349-6030
Practice Address - Street 1:140 NUTT RD
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3906
Practice Address - Country:US
Practice Address - Phone:610-983-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054467363AM0700X
PAOA002510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant