Provider Demographics
NPI:1861862112
Name:CORWIN, LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:CORWIN
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 1:15906 MILL CREEK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1797
Mailing Address - Country:US
Mailing Address - Phone:425-385-2009
Mailing Address - Fax:
Practice Address - Street 1:15906 MILL CREEK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012
Practice Address - Country:US
Practice Address - Phone:425-385-2009
Practice Address - Fax:425-939-0807
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005536363A00000X
WAPA60799617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2093302Medicaid