Provider Demographics
NPI:1679851604
Name:CONVERSE, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CONVERSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 278980
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-598-8567
Mailing Address - Fax:585-388-1483
Practice Address - Street 1:2212 PENFIELD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1756
Practice Address - Country:US
Practice Address - Phone:585-598-8567
Practice Address - Fax:585-388-1483
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY14960363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03368045Medicaid
NYJ400053246/GP 70008AMedicare PIN
NYJ400053247/GP BA0017Medicare PIN