Provider Demographics
NPI:1790020147
Name:BLAU, LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLAU
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 1:2373 G RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1002
Mailing Address - Country:US
Mailing Address - Phone:970-243-3061
Mailing Address - Fax:970-245-8369
Practice Address - Street 1:2373 G RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1002
Practice Address - Country:US
Practice Address - Phone:970-243-3061
Practice Address - Fax:970-245-8369
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5310363A00000X
COPA-0003862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant