Provider Demographics
NPI:1821079039
Name:RICHARDSON, LAURA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 ARDMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-4405
Mailing Address - Country:US
Mailing Address - Phone:412-247-3222
Mailing Address - Fax:412-247-3229
Practice Address - Street 1:1713 ARDMORE BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15221-4405
Practice Address - Country:US
Practice Address - Phone:412-247-3222
Practice Address - Fax:412-247-3229
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001521L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS58098Medicare UPIN
PA005872Medicare ID - Type UnspecifiedLAURA