Provider Demographics
NPI:1972661429
Name:PETERKIN, LAURA HOLLIS (PA)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:HOLLIS
Last Name:PETERKIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:HOLLIS
Other - Last Name:PETERKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:275 LANTERN BEND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2831
Mailing Address - Country:US
Mailing Address - Phone:281-440-0101
Mailing Address - Fax:281-440-6441
Practice Address - Street 1:275 LANTERN BEND DR STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2831
Practice Address - Country:US
Practice Address - Phone:281-440-0101
Practice Address - Fax:281-440-1153
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03086363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L26140Medicare PIN