Provider Demographics
NPI:1205247269
Name:WEBSTER, LAURISA ANN (MD)
Entity type:Individual
Prefix:
First Name:LAURISA
Middle Name:ANN
Last Name:WEBSTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8181 N CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8752
Mailing Address - Country:US
Mailing Address - Phone:208-772-0785
Mailing Address - Fax:208-762-2704
Practice Address - Street 1:8181 N CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8752
Practice Address - Country:US
Practice Address - Phone:208-772-0785
Practice Address - Fax:208-762-2704
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine