Provider Demographics
NPI:1740241256
Name:FARRIS, LAURA E (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
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 1:4341 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-2602
Mailing Address - Country:US
Mailing Address - Phone:301-262-1330
Mailing Address - Fax:
Practice Address - Street 1:128 LOUISE TER
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-7339
Practice Address - Country:US
Practice Address - Phone:410-914-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK519Medicare ID - Type Unspecified