Provider Demographics
NPI:1922240282
Name:RUPERT, LAURA ELIZABETH SELL (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH SELL
Last Name:RUPERT
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:SELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 W WILSON BRIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2217
Mailing Address - Country:US
Mailing Address - Phone:614-895-8747
Mailing Address - Fax:614-895-3246
Practice Address - Street 1:350 W WILSON BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2217
Practice Address - Country:US
Practice Address - Phone:614-895-8747
Practice Address - Fax:614-895-3246
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003263363A00000X
MI5601005481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35120137Medicare PIN
MIM35150067Medicare PIN