Provider Demographics
NPI:1790111490
Name:WINSTON, LAUREAN JADA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAUREAN
Middle Name:JADA
Last Name:WINSTON
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 1:321 REGENCY PARK STE 100
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1887
Mailing Address - Country:US
Mailing Address - Phone:618-416-7970
Mailing Address - Fax:618-416-7971
Practice Address - Street 1:321 REGENCY PARK STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1887
Practice Address - Country:US
Practice Address - Phone:618-416-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11502363A00000X
CA55629363A00000X
TXPA11166363A00000X
IL085004813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-008OtherTRICARE
TXP01912555OtherTRICARE
TX8HH169OtherBCBS
TX371011302Medicaid
TX599442YMAFOtherMEDICARE