Provider Demographics
NPI:1942759568
Name:KOMUDA, LAURIE (NP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:KOMUDA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-733-7598
Mailing Address - Fax:
Practice Address - Street 1:329 N SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1755
Practice Address - Country:US
Practice Address - Phone:315-471-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340655-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily