Provider Demographics
NPI:1689205262
Name:FARRIS, LAUREN M (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:FARRIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2529
Mailing Address - Country:US
Mailing Address - Phone:269-983-3455
Mailing Address - Fax:269-983-5920
Practice Address - Street 1:815 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2529
Practice Address - Country:US
Practice Address - Phone:269-983-3455
Practice Address - Fax:269-983-5920
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009726363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical