Provider Demographics
NPI:1811595499
Name:COOLIDGE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:COOLIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 ROAD 44
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2667
Mailing Address - Country:US
Mailing Address - Phone:509-543-9820
Mailing Address - Fax:509-545-6275
Practice Address - Street 1:1608 ROAD 44
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2667
Practice Address - Country:US
Practice Address - Phone:509-543-9820
Practice Address - Fax:509-545-6275
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3749207Q00000X
WAPA61114586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine