Provider Demographics
NPI:1013091594
Name:BRECKENRIDGE, LAURA (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BRECKENRIDGE
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 1:308 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1710
Mailing Address - Country:US
Mailing Address - Phone:650-357-7971
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2308
Practice Address - Country:US
Practice Address - Phone:650-873-4545
Practice Address - Fax:650-873-4544
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64476207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G644760Medicaid
CAE80917Medicare UPIN
CA00G644760Medicaid