Provider Demographics
NPI:1881630044
Name:MEDLIN, LAURA A (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PATRICK CT
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1743
Mailing Address - Country:US
Mailing Address - Phone:252-443-0400
Mailing Address - Fax:252-443-0572
Practice Address - Street 1:110 PATRICK CT
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1743
Practice Address - Country:US
Practice Address - Phone:252-443-0400
Practice Address - Fax:252-443-0572
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2749101KMedicare PIN
NC2749101JMedicare PIN