Provider Demographics
NPI:1720383615
Name:WALTZ, LAUREN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:WALTZ
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 1:1901 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-3270
Mailing Address - Country:US
Mailing Address - Phone:256-240-9660
Mailing Address - Fax:256-240-9636
Practice Address - Street 1:1901 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-3270
Practice Address - Country:US
Practice Address - Phone:256-240-9660
Practice Address - Fax:256-240-9636
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical