Provider Demographics
NPI:1992186662
Name:LAU, DEANNA (DO)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SOTOYOME ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4822
Mailing Address - Country:US
Mailing Address - Phone:707-303-1705
Mailing Address - Fax:
Practice Address - Street 1:121 SOTOYOME ST STE 203
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4822
Practice Address - Country:US
Practice Address - Phone:707-303-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A187852080P0006X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program