Provider Demographics
NPI:1982678652
Name:OBENAUF, LAURA LANETTE (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LANETTE
Last Name:OBENAUF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LANETTE
Other - Last Name:LUGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1682
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1682
Mailing Address - Country:US
Mailing Address - Phone:616-774-5221
Mailing Address - Fax:616-774-5391
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:MC 426
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-774-5221
Practice Address - Fax:616-774-5391
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q15846Medicare UPIN
N48650031Medicare PIN