Provider Demographics
NPI:1003235904
Name:MIRABDOLLAH, LAUREN ELVIRA (NP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELVIRA
Last Name:MIRABDOLLAH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELVIRA
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:77 CASA ST
Practice Address - Street 2:SUITE 201-204
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:805-269-1500
Practice Address - Fax:805-269-1585
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000334363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1508Medicare PIN